Skip to main content

Full text of "An index of differential diagnosis of main symptoms, by various writers;"

See other formats


il^eference Hibxavp 



AN i\dp:x of 
DIFFERENTIAL DIAGNOSIS 

Ol' MAIN S^'^I1'T()MS 



I'lllNTKD IS ESOLAND BY 
JOHN WRIGHT AXn SONS LTD.. BHISTOL 



PKHFACK TO THE SECOND EDITION 

Little need be said by way of preface to the second edition of this worlv • ti.e 
jrratity.ng sale of the first edition and the necessity there has been to reprint it 
several t.mes ,s .sufficient evidence tliat the book is one wliiel, the medical profession 
welcomes and ajipreciates. 

In this edition every article has been re^■ised and several new ones have been 
added. 

The elaborate- nuicx. which has been nmeh appreciated, has l,een made if 
possible, even more complete, and at the same time it has been simplified in some 
particulars : the relative importance of the entries in it are indicated more clearlv 
perhaps than was the case in the first edition, by the use of three deorees of type 

The dlustrations are nearly doubled in number ; the coloured plates especiallv 
havng been mcreased from sixteen to thirty-seven, and neither time nor expensV 
has been spared m the endeavour to make them characteristic of the conditions 
they represent. 

The size of the type- en.ployed is larger than before, m response to sug-vestions 
Irom readers, and consequently the pages have had to be enlarged also 

It became a question, therefore, whether the book should be published m tvvo 
.•olumes ; in the belief, however, that in a work in which numerous cross-references 
ire unavoidable it is advantageous to confine it within one cover, it has been 
lec.ded to keep it as a single book. The general character of the volume remains 
"tJierwise unchanged. 

It is hoped that this second edition will be as widelv welcomed as was the first • 
.nd that It will prove even more helpful in its primary purpose, namelv, to be of 
.SS.S anec in arriving at the diagnosis of the exact cause of particular symptoms. 

Cordial thanks are extended to many helpers who. whilst not eoutrihutinrv 
vritten articles to the volume, have n,-verthelcss assisted g.vatlx- u, ^ ariuus wavs^ 
specially to Dr. J). S. Davies. Mr. C. Thurstan Holland. Dr. A. C. .Jordan Dr" t' 
Vanier Laeey Dr. T. M. L.,.,. ,), ,,„dsay Locke, Professor Rutherlbrd Moriso.K 
'.r .Malcolm Morns. 1),-. II. J{. Xcuham, Dr. G. W. Nicholson. Dr. .1. II HylTc.l 
• .-. S. CillHi-t Scot.. Dr. W. P. Saunders, Dr. A. Reudle Short. Dr. Hugh Walsham" 
)r. S. A K. \\,isoM : .,lso to the ]{nyal Society of M,.lieinr. I|,.. (;„nio„ Mnsenn, 
•uys Jlosp.tal, ,1„. Sonll, K.-.t.-n, fVv.r ]|.,s,.„al. and ll„. London .School .,r 
ropieal M.-d,,.,,,,.. Also ,.. tl„. publishers and proprietors of various journals and 
••r..t hea s lor unl-nhng courtesy n, giving laeilities lor the use of copyright material 
■ un illnsi rations. 

Jli;ui'.i;Kr l''Hi-'.Neu. 
Liindiin. 

I''rliniiui/. I!) 1 7. 



Digitized by the Internet Archive 

in 2010 with funding from 

Open Knowledge Commons 



http://www.archive.org/details/indexofdifferentOOfren 



PREFACE TO THl-L FIRST EDmON 

Tins book is a treatise on the application ot differential diagnosis to all the main 
signs and symptoms of disease. It aims at being of practical utility to medical 
men whenever difficulty arises in deciding the precise cause of any particular 
symptom of which a patient may complain. It covers the whole ground of medicine, 
surgery, gynaecology, ophthalmology, dermatology, and neurology. 

Whatever the disease from which a patient is suffering, the importance of 
diagnosing it as early as possible can hardly be over-rated. The present volume 
deals with diagnosis from a standpoint which is different from that of most text- 
books, having been written in response to requests for an Index oj Diagnosis as a 
companion to the publishers' Index oj Treatment, issued in 1907. The book is an 
index in the sense that its articles on the various symptoms are arranged in al]jha- 
betical order ; at the same time it is a work upon differential diagnosis in that it 
discusses the methods of distinguishing between the various diseases in which each 
individual symptom may be observed. Whilst the body of the book thus deals 
with symptoms, the general index at the end gathers these together under the 
headings of the various diseases in which they occur. 

The Editor lays jiarticular stress upon the importance of using these two parts 
of the book together. Unless reference is made freely to the general index, the 
reader may miss a number of the places in which is discussed the diagnosis of the 
disease with which he has to deal : for while each symptom is considered but once, 
each disease is likely to come uj) for diseussioii inider the heading of each of its more 
important symptoms. 

The guiding princijile throughout has been to suppose that a particular 
syini)tom attracts special notice in a gi\en case, and that the diagnosis has to be 
established by tlifferentiating between the various diseases to which this symptom 
may be due. One of many difficulties arising during the construction of the work 
was that of deciding where to draw the line as regards symptoms themselves. The 
<-xcIusion of many borderline headings such as " Dullness at the base of one lung." 
■ Inability to breathe through the nose."' and various signs such as Romberg's. 
Stcllwag's, Von Graefe's, and so forth, nuiy ])erhaps seem arbitrary ; but reference 
to the minor symptoms and physical signs which have not been thought sufficiently 
miportant to merit se|)arate articles will be found in the general index a I I lie end 
of the volume. 

Tre;itnieiit. patliology. uiid |)rognosis .uc uol dcall willi cxcci.l ui so far as tlii-y 
may bear upon (liff<Tential diagnosis tlic euiploynicul of salieylnlcs. for instance. 
in distinguishing acute rheiimatie from other forms of ,iil hiil is : Ihc us,- of (In- 
microscope in distinguishing malignant neoplasins Iroin iiilJ.uMui.ihn \ or oilier 
tumours: the value of the hipse of lime in .lislinguisliing l)el\ve<u I nlHirulous ;uid 
ineningoeoeeal meningitis. 

Coloured plates and other illustrations have been introduced freely wherever 
It was thought they might be helpful in diagnosis. .Most of them are original, but 



^riii PREFACE 

a few are ivprocUiccd Ironi other sources, and thanks are due to the authors and 
publishers who have kindly lent them. 

So iar as the Editor is aware, although there exist indices of symptoms, and 
medical works in which various maladies are discussed in alphabetical order, the 
present Index of Differential Diagnosis of Main Symptoms is unique in medical 
literature. It rests with the medical profession to decide whether it strikes the 
mark at which it aims. There must be room for improvement in many respects, 
notwithstanding the great amount of time and labour that have been bestowed 

upon it. 

IIowe\cr this may be, the work undoubtedly owes much of what value it 
possesses to the suggestions and kindly help of the many contributors who have 
assisted in its making ; and to the practitioners and the authorities of various insti- 
tutions who have generously lent the material for many of the illustrations. Indeed, 
it is difficult to see how the book could have been produced in its present complete- 
ness without their willing collaboration : they are enumerated elsewhere, and to all 
of them the Editor tenders his sincere thanks. 

Criticisms and suggestions are invited, and will hi' received with gratitude by 
tlie Editor. 

Hkkbf.rt French. 

62, Wiinpole Street, Londnu. W. 
March, 1912. 



LIST OF 
CONTRIBUTORS AND THEIR SUBJECTS 

VViLLiAM C'kcii. Bosanquet, m.a. Oxon., m.d., p.r.c.p. ; Pliysician, Brompton Hospitiil lur 
Consumption and Diseases ol' tlic Chest ; Pliysician, Charing Cross Hospital. 

Blood per anum, 75. — Colic, 114. — Glycosuria, 260. — Meleena, 385. 

K. Farquiiar Buzzard, m.a., m.ij. Oxon., b.ch., f.r.c.p. ; Physichiri In Out-Patieiits at St. Tliomas's 
Hospital and at the National Hospital for the Paralyzed and I'.pili ptie. Queen Square ; Con- 
sulting Neurologist to the Royal Free Hospital and to the llospitid Inr Diseases of the Throat, 
Golden Square. 

Amnesia, 19. — Ataxy 55. — -Aura, 67. — Claw-foot, 109. — Claw-hand, 109. — Facies, abnormalities of, 233. — 
Girdle-pain, 260. — Incontinence of faeces, 313. — Irritability, 323. — Knee-jerk, abnormalities of the, 357. — 
Pain in the extremity (lower), 438. — Pain in the extremity (upper), 442. — Pain in the face, 446. — 
Paralysis, facial, 491. — Paralysis of one extremity (lower), 4 '6. — Paralysis of one extremity (upper), 500. 
— Sensation, some abnormalities of, 604. ^Speech, abnormalities of, 623 

Pkrcv .John Ca.mmidge, m.d. Loud.. n.iMi. (anil). 
Cammidge's pancreatic reaction, 100. 

IIerbkrt I.. E.vso.v. m.d.. m.^. I-ond. : .Senior Ophtliahiiie .Surgeon. (Juv's Hospital. 

Diplopia. 174. Enopblhalmos, 217. — Epiphora, 220 — Exophthalmos, 229. — Eye, acute inflammation of, 
231. — Nystagmus, 407. — Ophthalmoscopic appearances, notes on, 415. — Ptosis, 540. — Pupil, abnormalities 
or the, 551. — Strabismus, 649. Ulceration of the cornea, 733. — Vision, defects of. 757. 

.loiiN W. H. KviiE. M.I)., M.S. Diirli., D.i'.ii. (anil).: Direetor of the Baeteriologic al Depaitinent, 
(Juy's Hospital : I.eetiiicr on IJaeleriologv to the .Medieal .School and Dental .Sehool, (iiiv's 
Hospital. 

Bacteriuria, 69. 

Carev F. CoOMns, M.D., M.ii.i-.i". : Assistant I'hysieiaii, Bristol (iciieral Hospital: ( liiiieal l.iitnrer 
in Meilieine, I'uiveisity of Bristol. 
Pulse, Irregular, 544. 

Ili;iiiii;iir .^I()lll.I.^• Fi.i;nnEic, m.a.. m.d. Canil)., i .R.c.i-. ; Physician, St. Bartholomew's Hospital : 
Physician in Charge of Diseases of Children Department, .St. Bartholomew's Hospital ; Con- 
sulting Physician, h'-ast l.oiiilou H<)s])ital for Childien. 
Hoad.T,cho, 293. Vomiting. 763. 

IlKitiiEiiT l'"iti;N(ii. M.A., M.D. Oxoii,, i.u.c.i'. ; I'hysiciaii, I'athologisl , and I.eeliircr, (Jny's Hospital. 

Accentuation of heart sounds. 1. Accoucheur's hand, 2. Acetonuria. 3. — Albuminuria, 4. — Albumosuria. 
16. — Allocholria. 17. Aniemla, 20. -Ankle clonus, 39. — Ascites, 43. — Atrophy, muscular, 59. — Atrophy, 
testicular, 66. Babinski's sign, 68.- Bl.ack specks before the eyes, 71. -Bleeding gums, 72. Blood- 
pressure, .abnormal, 81. Borborygml, 82. — Br.adycardia, 82. Bnadypnooa, 84. Breath, foulness of the, 
86. -BuIlX", 96. Richexla, 99. Charcot Loydoii crystals. 102. Chest, bloody oflusion in, 102. Chost, 
pus In, 103. Chost, serous effusion in. 104. Cheyne Stokes rosplr.ation, 107. Chordee, 108. Chyluria. 
108. Clubbed Angers, 111. Coma, 117. Cr.ackling, egg-.shell. 161. Crepitus, 152. Curschmann's 
spirals, 153. Cyanosis, extreme, 161. — Cystliiurl.a, 1>)1. Dead lingers, 162. DlaceturLa, 170. Diazo- 
reaction, 173. Dilatation of the stom.ach, 173. Discharge, naa.al. 178. Dysphagia, 194. Dyspncea. 199. 

Emphysema, surgical. 203. Enlargomont of the forehead. 203. Enlargement ol tho heart. 206, 
Eoslnophllla. 218. Ei-ylhoma, 222. Fa-'cos passed per urethram. 238. Fatty stools, 239. Fr.acture, 
spontaneous. 242 O.-ill bladder onlargomont, 262. Grinding of tho tooth during sleep, 65. Haima- 
tamosls. 2G6, Hoemogloblnurla, 284. Hajmoptysis, 286. -Heartburn, 296. Homiiinopsia, 300. 
Hemiplegia. 302.- -Hiccough, 307. Hyperacusls, 308. Hyperpyrexia, 309. — Hypothermia, 310. Impo 
tenoe, 3 2. IndlcanurLa, 314. Jaundice. 324. Leucocytosls, 359. I oucopenia, 361. Limping in 
children, 362. Lymphatic gland enlargement, 376. Mar.asmus, 384. Moryoism, 388 Meteorism, 388. 
Mucus in the urine, 399. Nightmares, 402. Noises in tho ho.ad, 405. Obesity. 408. (Edema, sym- 
metrical, 410. Opisthotonos, 417. Orthopna).a, 418. Ox,-iIurla, 423. P.-vln in tho breast, 429. P.aln in 
the eye, 445. P.aln In the lll.ac fossa (loft), 462. Pain In the lilac fossa (i-ightl, 454. Pain, inter- 



X tX)XTRIBUTORS AND THEIR SUBJPX'TS 

scapular, 461. Pain in the shoulder, 474. -Palpitation, 484. Paralysis, laryngeal, 494. Paraplegia, 
510. -Parasites, intestinal, 519. Peristalsis, visible, 521. Phosphaturia, 522. Photophobia, S24. 
Pigmentation in the mouth, 526.- Pneumaturia, 52&. Pneumothorax. 530. Polycythaemia, 532. 
Polyuria, 534. Priapism, 537. Ptyalism, 542. Pulsation, undue abdominal aortic, 543. Pulses, unequal. 
550. Purpui-a, 552. Pus in the stools, 657. Reaction of degeneration, 583. Reduplication of heart 
sound, 587. Regurgitation of food through the nose, 588. -Retraction of the gums, 589. -Retraction of 
the head, 589. Risus sardonicus, 598. Skodalc resonance, 611. Smell, abnormalities of, 611. Snoring, 
613. Sore throat, 613. -Spleen, enlargement of the, 628. Sputum, 641. Stertor, 647. Strangury, 649. 
-Stridor, 650.- Succussion sounds, 651. Swelling, pulsatile, 693. Swelling of the tongue, 698. Tache 
cer^brale, 702.— Tachycardia, 702. Taste, abnormalities of, 705. Tenesmus, 716. Thirst, extreme, 719.- 
Trismus, 729. —Urate deposit in the urine, 740. Dric acid deposit in the urine, 741. Veins, varicose 
abdominal, 748. Veins, varicose thoracic, 750. Weight, loss of, 768. 

AiiCiiiBALD Edwu. Gaiikoij, C.M.G., .M.A., .M.i). Oxoii.. 1 .K.c.i>., 1 .U.S. : I'livsiciitii. St. BarthoIomcwV 
Hospital : Consulting Physician to the Hospital for Sick Children, (Jreat Ornioiid Street. 
Urine, abnormal coloration of, 742. 

(;i;ouGE Ernest Gask. i .k.c.s. : Sin-oeon with Charge of Out-iiatients, St. Bartholomc\\ "s Hospital : 
.Toint Lecturer in Siiroci\ . .St. Bartholomew'.s Hospital Medical School. 

Discharge from the nipple, 131. — CEdema, asynunetrical, 410. Pain in the jaw, 462. — Pain in the umbilical 
region, 483. Rectum, abnormalities felt per, 584. Rigidity of the abdomen, 592. Stiff neck. 647. 
Swelling, axillary, 666. Swelling on a bone, (67. — Swelling of the face, 673. — Swelling, femoral, 674. — 
Swelling in the iliac fossa, 676. Swelling of the jaw (lower), 683.- Swelling of the jaw (upper), 685. 
Swelling, popliteal, 691.-- Swelling of the salivary glands, 694. -Swelling, scrotal, 695. — Thyroid gland 
enlargement, 721. Ulceration of the leg, 736. Ulceration of the tongue, 738. 

Hastings CiiLFOBD, f.ii.c.s. ; Considting .Surgeon. Kiugvvood Saiiatoriuiii. Heading. 
Dwarfism, 186. 

.Artiiuk Fkedi;iuck Hihst, m.a.. .m.d. Oxon., f.r.c.p. : I'hysieian and I'hysician Tor Nervous 
Diseases and Lecturer on Therapeutics, Guy's Hospital. 
Constipation, 121. — Fullness, sense of, 243. 

Robert HiiTCHisoN, m.ij., cm. Kdin., i-.r.c.p. ; Physician to tlie London Hospital : Physician with 
Charge of Out-patients to the Hospital for Sick Children, Gicat Orniond Street. 

Appetite, abnormal, 42. Diarrhoaa, 170. Flatulence, 240. Indigestion, 315. Pain in ihe epigasti-ium, 
436. Pain in the hypochondrium Heft), 450. Pain in the hypochondrlum (right), 450. 

Arthi K John Jex-Blake. m.a., m.b., b.ch. Oxon. m.r.c.p. : Senior Assistant Pliysician, St. GeoigcV 
Hosjjital : Assistant Physician. Brompton Hos])ital for Consumption. 

Contractions, 131. Contractures, 139. Convulsions, 143. Cramps, 150.- Epistaxis, 221. Gangrene, 255. 
Gangrene of the lung, 259. Insomnia, 320. Pain in the chest, 430. -Pain in the limbs, 463,- -Rigors, 
or chills, 694. Swelling, abdominal, 656. Tenderness in the chest, 706. - Tenderness in the scalp, 710. 
Tenderness in the spine, 712. -Tremor, 724. 

Sir i\L\lcolm Morris, Bart., K.c.v.o., i-.r.c.s. Edin. ; Consulting Surgeon. Skin Department. 
St. Mary's Ho.spital ; Surgeon, Skin Department, Seamen's Ho.spital. 

Baldness, 70. Sore finger, 239. Flushing, 241. Futigous affections of the skin, 246. Lips, affections of 
the red part of the, 365. Macules, 382. Nails, affections of the, 399. Napkin region eruptions, 400.- 
Nodules, 402. Papules, 487. Pigmentation of the skin, 527. Prm-itus, 540. Pustules, 557. Scabs, 599. 
Scaly eruptions, 601. Sweating, abnormalities of, t54. Tiunours of the skin, 731. Ulceration of the 
face, 735. Ulceration of the foot, 735. Vesicles, 753. Wheals, 771. 

HoBEin P, l{o\M.ANi)s. M.B., M.S. Loud., 1 .R.c.s. : Surgeon. Guv's Hospital : Lecturer on Anatomy. 

Guy's Hosjiitiil .^ledical School. 

Club foot, or talipes. 111. Curvature, spinal, 153. Swelling, inguinal, 678. Swelling, Inguinoscrotal, 682- 

.I.vMES K. H. S.\wvEH, .M.A.. M.D.. ii.cii. Oxon. : Assistant Physician, General Hospital. Birmingham. 

Bruits, cardiac, 89. Deformity of the chest, 167. Heart impulse, displaced, 297. Thrills, precordial, 720. 

Frkderick John Smith, m.a., .m.o. Oxon., f.r.c.p., f.r.c.s. : Physician and Senior Pathologist. 
London Ho.«pital : Consulting Physician to the City of London Dispensary and to the National 
Orthopjedic Hospital. 

Breath, shortness of, 87, Cough, 148. Delirium, 169.— Gait, abnormalities of, 261. Lineffi albicantes, 
365. Pain in the back, 427. Pyrexia without obvious cause, 571. 



CONTRIBUTORS AND THEIR SUBJECTS xi 

'I'lioMAS George Stevens, m.d., b.s. Lond., m.r.c.p., f.r.c.s. : Obstetric Surgeon, St. Mary's 
Hospital ; Gyna^eolooical Surgeon, Hospital for Women, Soho Square : Physician to In- 
patients, Queen Charlotte's Hospital. 

Amenorrhcea, 17. Discharge, vaginal, 185. Dysmenorrhcea, 192. Dyspareunia, 193. Dystocia, 199. 
Menorrhagia, 385. Metrorrhagia, 390. Metrostaxis, 392. Pain, bearing down, 427. Pain in the pelvis, 
467. Prolapse of the uterus, 538. Sterility, 645. Swelling, mammary, 685. Swelling, vulval, 699. 

Id ■<-,i;i.!. H. .JocKi.vN S\v.\x. .m.is.. .-m.s. LoiuI., i .it.c'.s. : Suri;coii, t'aiiccr Ilosjiitai, Bioiiiptoii. 

Anuria, 39. Discharge, urethral, 181. Enuresis, 218. Hasmaturia, 276. Kidney, enlargement of, 352. 
Micturition, abnormalities of, 393. Pain in the Penis, 469.- Pain in the perineum, 474. Pain in the 
testicle, 477. Pyuria, 674. Sores, penile, 617. Sores, perineal, 619. Sores, scrotal, 621. 

Ki(KiJi;uitK T.ivi.oit, M.D. Lund., i.r.c.p. ; Coiisultiiiy Physician, Guy's Hospital, and Kvelina 
Hospital for .Sicl; C'liikhen : Physician, .Seamen's Hospital, Greenwich. 
Pyrexia, prolonged, 563. 

Philip Tlrner, b.sc, m.b., M.S. Lond., f.r.c.s. : .\ssistant Surgeon, Guy's Hospital : Drmoastrator 
of Operative Surgery, Guy's Hospital Medical School. 

Deafness, 163. Earache, 202. Otorrhoea, 421. Tinnitus, 723. Vertigo. 750- 

\Vii.i.iA.\i Half. Wuite, .m.d. Lond., m.d. Dub., f.r.c.p, : Senior Physician and Lecturer on Medicine, 
Guy's Hospital, 

Joints, affections of the, 337. Liver dullness, deficient, 366. Livei-, enlargements of the, 366. Mucus in 
the stools, 398. Pain, abdominal, 426. Sand, intestinal, 599. 



LIST OF COLOURED PLATES 

Platk I. — Renal tube casts __--_-.- 

A, Hyaline; B^ Waxy; C) Uynline cast containiug small ciystals of cnlcium oxalate; D, Blood; 
E, Leucocyte ; F. Epithelial ; G, Granular ; H, Fatty. 

Plate II.— Red and wliite blood corpuscles ,.--.- 

A, Xormal red ; B, Megalooytes and microcytes ; C, Normal red corpuscles made angular by imperfect' 
fixation; D, Crenated red coi-puscles ; F, Poikilocytes ; F, Nucleated red corpuscles — (1) Normoblasts, 
(2) Mefjaloblasts. (3) Gigantoblasts ; G, Punctate basophilia and polychromasia ; H, Small lymphocyte: 
I, Indeterminate lymphocyte ; j. Large hyaline lymphocyte ; K, Polymorphonuclear corpuscle ; L, Coarsely 
granular eosinophile coipuscle ; M, Myelocyte ; N. Eosinophiie myelocyte ; o, Easophile corpuscle. 

Plate III. —Blood film in pernicious antemia _.---. 

showing poikilocytes, microcytes, megalocytes, nucleated red cells, and punctate basophilia. 

Plate IV. — Blood film in spltnnincdiillary leuktemia _ . . . , 

Showing five neui in|.!iil.> tm .In, \ ti.-^, one eosuiophile myelocyte, three basophile cells, and one binucleated 
red cell, in addition to im.iui.W ."■mi pu>.'les. 

Plate V. — Blood film in lymphatic leukaemia ...... 

Sliowing a lai^e increa-se in the small lymphocytes. 
Plate VI. — Blood film in malaria ._..__, 

Showing three malarial panisites of the ring type. 
Plate VII. — Pigmentation of the skin due to arsenic . . . _ . 

Plate VIII.—Koplik's spots . . , . ... 

Plate IX.—Pellaora _....._.. 

Plate X. — The hand of u i)ellagrin -.-,_.. 

Plate XI. ^ — ^Acute inflammations of the eye -._,_. 

A, Acute conjunctivitis ; B, Acute iritis ; C, Glaucoma ; D, Phl^'ctenular conjunctivitis : e. FoIUcuUir 
conjunctivitis. 

Pl.\te XII. — Acute inflammations of the eye .--_-- 

F, Chi-onic blepharitis ; G) Interetitial keratitis ; H, Ti'aclioma ; |, Hypopyon and ulcer of cornea. 
Pi^\TK XIII. — ^Symmetrical gangrene of the fingers in Raynaud's disease 
Plate XIV. — Gangrene of the foot _ - . . . . 

Plate XV. — Bladder appearances seen thrtniiih the cystoscope ... - 

A, Blood-stained urine issuing fi-om the ureter ; 8» Pmnleut urine issmng from the ureter ; C, Conges- 
tion round a ureteric orifice in calculous pyehtis ; d, The reti-acted ureter common with descending renal 
tuberculosis ; E, Tuberculous ulceration around the ureteric orifice in descending tuberculosis. 

Plati: XVI. — Bladder appearances seen through the cystoscope - _ - - 

F, Pedunculated carcinoma of bladder; G-, Pedunculated bald carcinoma of bladder; h, L'ric acid 
calculus in bladder; |, Appearance at tlie urethral orifice in bilateral adenomatous enlargement of the 
jirostate ; K, Bilhaiv.ia hasmatohia. 

Plate XVII.— Multiple bleeding narvi of tlu- tongue, niuutii. and ehtek 

Plate XVIII. — Familial acholuric jaundice _-_.-. 

Plate XlX.—Ophthalmoscopic appearances _-,-.. 

a. Physiological cup ; &, Congenital crescent ; c. Pigmented crescent in disc mai^gin ; d, Colobomu 
of choroid ; e, /, Opaque nerve fibres ; y, Advanced syphilitic choroiditis ; A, t", The myopic crescent ; 
k, I, Eecent optic neuritis. 

Plate XX. — ^Ophthalmoscopic appearances - - . . _ 

7«, 11, Primary optic atrophy ; o, Tln-ombosis of the central retinal vein ; p, q, i\ .Vlbuminnric retinitis ; 
.V. Embolism of the central retinal artery ; r, Detachnipnt of the retina : r, Glaucomatous discs ; ir. Tubercles 
in the choroid ; x. Hypermetropic astigmatism. 

i*LATE XXI.^Pigmentation of the tongue and nioutli in Addison's disease 

Plate XXII. Picnicntation of tlic mouth in j)ei'nicrous aniemia 



LIST OF I'OLOUREI) PLATES 

PL.vn; XXIII. — Intestinal sand -------- 

1. True intestinal sand ; 2. False intestinal sami. 

PLiVTE XXIV. — Pityriasis rubra ------- 

Plate XXV. — Diagram showino tlie radicular sensory areas of the human body - 
Plate XXVI.— .Sore throats -_.,._-- 

I. Ordinary hypenemio sore throat ; II. Jlild follioular tonsillitis ; III. .Severe follicular tonsillitis ; 
IV. Left-sided quinsy ; \. Syphilitic sore throat. 

Plate XXVII. — Sore throats _--.---- 

VI. Mild diphtheria, simulating follicular tonsillitis ; VII. Diphtheritic sore throat, of medium severity ; 
VIII. Diphtheritic sore throat, severe, showing spread of membranous exudate to palate ; IX. Phlegmonous 
diphtheria ; X. Vincent's angina. 

PL.\rE XXVIII. — Bacteria and blood parasites _ . . - - - 

A, ilalaria, early ring form ; B, Malaria, ordinary ring form ; C, Malaria, m,ature tertian ; D, Malaria, 
tertain, ready to sporulate ; E, Malaria, crescentic ; F, Filaria embryo; G, Trypanosoma Gambiense ; 
H, Leishman-Donovan bodies obtained by splenic puncture; I, Spirochaeta Obermeieri of relapsing fever; 
J, Spirochaeta palhda of syphilis; K. Tubercle bacilli and pus cells; L, Diphtheria brcilli ; M, Vincent's 
angina. Spirilla and fusiform bacilli ; N, Meningococci within a leucocyte ; o. Pneumococci and pus cells ; 
p. Staphylococci and pus cells ; Q, Streptococci and pus cells ; R, Gonococci. in and outside of pus cells ; 
S, -A.ctinomyces ; T, Tetanus bacilli. 

Pl-vte XXIX. — Splenomegalic polycytliBcmia ------ 

Plati-: XXX. — Po])liteal aneurysm ..-.--- 

Plate XXXI. — Cirsoid aneurysm -------- 

Plate XXXII. — Cancer of the tongue : very early conditions . - - - 

P1.ATE XXXIII.- Ochronosis --------- 

Plate XXXIV. — Urine tests --------- 

1,2,3. The three stages of the sodium nitroprusside test for acetone. 4, 5, 6. The same in a urine 
containing no obvious acetone. (I and 4, noi-mal urine ; 2 and 5, the appearance after adding caustic soda 
and sodium nitroprusside : 3 and 6, the appearance after adding acetic acid, 3 being positive, 6 negative, for 
acetone). 7, Kothera's test for acetone, p. Ferric chloride reaction of diacetic acid. 9, Indicanuria test. 
to, Melanuria- 1 1, Diabetic urine. 12, The fluorescent reaction of urobilin. 

Pi..\TE XXXV. — Urine tests and Gunsberg's test ----- 

1 , Iodine test for bile pigment in urine. 2, Gmelin's reaction for bile pigment in urine. 3, Gunsberg's 
test for free HCI in gastric juice. 

Pl.vti: XXXVI. — TuJ)erculin reactions ------- 

Cutaneous reaction (von Pirquel) ; Dermal reaction {Woodcock). 
Pi..\iK XXXVII. — Tuberculin reactions ------- 

Dnroinl reaction (.Vor«) : Oplithalmo-test iCulmellf). 



ILLUSTRATIONS IN THE TEXT 



F7G. 

1. — Accoucheurs luind 
2. — Method of making a blood-film 
•i. — Miculicz's syndrome 
4. — Temperature chart in leukiemia 
■>■ — .. ,, relapsing fever 

<), 7. — .. „ malaria 

'i- — .. ,, quotidian ma- 

laria - 
'■>■ — .. .. double tertian 

malaria 
10. — ,. ,, complex ma 

laria - 
11. — ,, ,. to illustrate ir- 

regular pyrexia 
in chronic ma- 
laria 
12. — Pyrexia in cirrhosis _ _ , 
13. — Pseudoleukaemia infantum 
14. — Facies previous to myxa-dema 
15. — Myxirdema facies - - 

Ifi. — Hands in iiiyxcrdcnia 
17. — Maliyiiant kit supraclavicular glands 
18.— Hydatid hookkts - 

m. — Infantile paralysis - 
20. — Tooth's peroneal palsv (bov) 
21.— „ ., ' (girl) 

22. — Wrist-drop from diphtheria 
23. — E.'itragenital chancre 
24. — Cancrimi oris - - - - 

25. — Ama?ba histolytica and A. coli 

26. — Ova of bilharzia ha>matobia - 

27. — Ankylostomum duodenale 

28-9.— ■ „ ova 

30. — Spectrum of oxyhjemoglobin - 

31. — „ reduced hiemoglobin 

32. — ,, carboxyha;moglobin - 

33. — „ alkaline ha^matiii 

34. — ,, acid haematin - 

35. — ., methicmoglobin - 

36. — .. urobilin 

37—8. — Heart-block electrocardiogram 

39. — Bruits of mitral stenosis - 

40. — Flint's murmur - - - - 

41. — Skiagram of phthisis 

42. — „ sarcoma of lung - 

43. — Cheyne-Stokes breathing 

44. — Claw-foot ----- 

45. — Syringomyelic claw-hand 
46. — Clubbed fingers with pulmonary 
stenosis ----- 

47. — Habitual constipation 
48. — Dyschezia - . - . - 

49. — Time relations of food in large bowel 
■)0. — Post-dysenteric atony and paresis of 
colon ------ 

51. — Constipation due to lead poisoning 

52. — ,, with mucomembranous 

colitis - - - 

53. — .Skiagram of carcinoma of splenic 

4 flexure 
54. — .. bismuth enema and 

carcinoma coli 



PAGE 

3 
21 



60.— ( 
61. 



68.—' 
69. 



79 


85 


80 


86 


80 


87 


80 


88 


80 


89 


80 


90 


80 


91 


80 


92 



95 


96 


103 




105 


97 


107 


98 


109 


99 


110 






100 


111 


101 


122 


102 


122 


103 


123 


104 




105 


123 


106- 


124 


108 




109 


124 


110 




in- 


125 


ns 




114 


126 


115 



PAGi: 
The colon in Hirschs])rung's disease 127 
Visceroptosis - - - - - 127 
Athetotic hand - - - 132 

Volkmann's paralysis - - 141 

Dupuytren's contracture - 142 

Contracture after a burn - - 142 

Skiagram of caseous bronchial gland 149 
,, carcinoma of bone - 152 

— Osteitis deformans - - - 155 

Deal-porter's bursa - 156 

Myopathic lordosis - - - 156 

Morbus coeruleus, pulmonary stenosis 157 
Caseous gland seen with bronchoscope 158 
-Vena cava superior obstructed by 

aneurysm - - - - 

-Skiagram of miner's phthisis - 
•Temperature chart of pneumonia 

and empyema - . - 
■Cystin crystals 
■Politzer's acoumeter 
■Tuning-fork with foot-piece 
Galton's whistle 
-Rickety chest outline 
Normal adult chest outline 
Pigeon chest outline 
Fibroid lung, chest outline 
Knipliyscniatous chest outline 
Hoiniiiiynious double images 
Criissctl doidjie images - 
Effects of paralyses of ocular muscles 
Transillumination of the antrum 
Rickety dwarfism 
Achondroplasia 
Osteogenesis imperfecta 
•Cretinism - - . . 
Pituitary infantilism 
•Mongolism - - - - 
Anangioplastie infantilism 
Ateliosis - 

Progeria - - 

Tooth-plate im])actcd in larynx 
Bean in oesophagus 
Bismuth skiagram with epithelioma 

of a?sopliagus - - - - 

Stcuoscd cardiac end of tesophagus 
Ididpaihic ililatation of oesophagus 
Vena cava superior obstruction by 

aneinysm - . - - 208 

Skiagram of aneurysm - - 209 

Temperature chart in pellagra 225 

Meningocele of face - - - 230 

Cretin with frog-belly - - - 233 
Jlyxffidema - - - 234 

Face previous to myxoedcma - 234 

— Congenital syphilis - - 234 

Hutchinsonian notched teeth 234 

.Myopathic facies - - - 235 

Rirc en travers - - - 235 

— Myastlicnic facies 235 

F.xojilitliahnic goitre 236 

I'aralvsis aaitans - - . 230 

Tabetic facies - - - - 236 



158 
159 

160 
161 
164 
164 
165 
167 
167 
167 
167 
167 
176 
176 
177 
180 
186 
187 
187 
189 
189 
190 
190 
190 
191 
195 
195 

190 
197 
198 



LIST OF ILLUSTRATIONS 



FIG. 




PAGE 


116. 


—Acromegaly ----- 


237 


117.- 


—.Achondroplasia - . . - 


237 


118- 
120.- 


9. — Mongolian idiot - - - - 
— Facies of familial lenticular degenera- 


237 




tion _ . - - - 


238 


121. 


— Sarcina: ventriculi 


241 


122.- 


—Skiagram of normal stomach - 


245 


123.- 


— Favus _ . - - - 


246 


124.- 


— Cholcsterin crystals 


254 


125.- 


—Local asphyxia in Raynaud's disease 


256 
257 


126. 


—Raynaud's disease, fingers 


127. 


— Phenyl-glucosazonc crystals - 


262 


128. 


—Skiagram of hour-glass stomach 


268 


129.- 


— .. normal stomach 


269 


130. 


— .. carcinoma of stomach 


269 


131 . 


— .. .. ,. pyloric 


270 


132.- 


., diffuse 


270 


133. 


- .. renal calculus - 


279 


134. 


— .. tuberculous kidney 


280 


13.3. 


vesical calculus - 


282 


136. 


— .. pneumonia 


289 


137.- 


—Hydatid cyst of lung 


291 


138. 


—Connections of optic ner\-es and 






tracts ----- 


300 


139.- 


—Bilateral temporal hemianopsia 


300 


140- 


1. — „ homonymous hemianopsia 


301 


142.- 


-Temperature chart of hypothermia 






with mitral stenosis - 


311 


143.- 


—Hypothermia in malignant cachexia 


312 


144.- 


—Skiagram, bismuth shadow of a 






dropped and dilated stomach 


318 


14.5.- 


-Pyrexia with carcinoma of liver 


326 


146.- 


—Skiagram of gall-stones - 


327 


147. 


— Leucin crystals - - - - 


333 


148. 


-Tyrosin crystals - . - - 


333 


149. 


-Temperature chart showing effect of 
salicylates in 
acute rheuma- 






tism 


338 


150.- 


.. of gonococcal ar- 






thritis - 


338 


151. 


— ., ..in acute gout 


339 


152.- 


— ., .. in rhcumatoi'l 






arthritis 


341 


153. 


— .\cutc rluinnaloid arthritis 


342 


154.- 


—.Skiagram of hands in acute rheuma- 






toid arthritis - . - . 


342 


155. 


— HebcrdcM's nodes - - - - 


343 


156.- 


— Hhcuinaldid arthritis, transparency 






of bones in 


344 


157. 


—Henoch's purjmni 


345 


158.- 


—Gout 


345 


159. 


—Skiagram of chniiiic gciul 


346 


160- 


1. — Pads (m fingers - 


347 


162. 


— Charcot's joint 


349 


163. 


—Skiagram of Charcot's hip 


3.-.0 


164- 


5. — Pulmonary osteo-arthropattiy 


3.-,1 


166. 


— Pyelogra])liy 


3.1C, 


167. 


-Pvrexia in cirrhosis 


371 


168. 


-Ilodgkin's disease 


377 


169. 


Still's disease 


.•f77 


170. 


Macular sypliili.lcs 


383 


171. 


- Hirschsprung's disease 


3H9 


172. 


Mucous <ast of iiitcstiuc 


3ilK 


173. 


- Nodular leprosy - 


101- 


174- 


5. Ilypcriieplironia patient 


MIH 


176. 


- DvstropiiiM adiposogenilalis 


K)9 


177. 


- Milr.,y's diseas.. - 


HI 


178. 


.\ngioneurolic (cdcma 


412 


17U. 


- .Meige's disease 


414 


180. 


SUiagiani of large lliviiiiis gland 


419 


181. 


(al.-iMiii nxMlale crystals 


423 



FIG. PAGE 

182. — Skiagram of bismuth in normal colon 426 
183. — ,, ,, dropped colon 426 

184. — „ aneurysm - - - 435 

185. — „ spine on os calcis 440 

186. — „ cervical rib in child - 443 

187. — .. ,, „ adult - 443 
188-91. — Sensory areas of face, head, and 

neck ----- 448 
192. — Skiagram of ureteral calculus - - 455 
193. — Temperature chart in coli bacilluria 4,56 
194. — Tuberculous ea;cum - - 458 
195. — Skiagram of lumbar caries - - 460 
196. — Electrocardiogram of auricular fibril- 
lation - . - - . 4gg 
197-200. — Facial paralysis - - 491-2 
201 . — Bilateral facial palsy - - 493 
202. — Hemiatrophy of face - - - 494 
203—4. — Diagrams of Brown - Sequard 

paralysis - - - . 497 
205. — Diagram of lumbosacral plexus - 500 
206. — Peripheral neuritis in leprosy - 505 
207. — Serratus magnus paralysis - - 506 
208. — Diagram of cervicobrachial plexus - 507 
209. — Atrophy in hand from cervical rib - 508 
210. — Sensory localization in the cord - 518 
211. — Reflex centres in the cord - 518 
212-3. — Head of tienia solium - 519 
214. — ,, „ mediocanellata - 519 
215. — • ,, Bothriocephalus latus - 519 
216. — Ovum of taenia solium - - 520 
217. — ,, ascaris lumbricoides - 520 
218. — Trichocephalus dispar in the colon - 520 
219. — Ovum of trichocephalus dispar - 521 
220. — Ankylostomiasis of the duodenum - 521 
221. — Triple phosphate crystals - - 524 
222. — Pigmentation in exophthalmic goitre 527 
223-4. — Sypliilitie leukomelanodermia - 528 
225. — Pigmentation of skin from arsenic - 529 
226. — Skiagram of pyopneumothorax - 531 
227. — Ptosis and healed gumma of face 541 
228. — Paralysis of internal rectus - - 541 
229. — Ptosis from syphilis - - - 541 
230. — Facial paralysis from syphilis - - 541 
231. — Klcctrocardiogram showing extra- 
systoles ----- 544 
232.- Polygraj)!! tracing of incomplete 

heart-block - 545 
233.- .. ,, showing heart- 
block - 546 
234. ., ,, of ventricular 

extrasystolc - 547 

235. — Pulsus bisfcriens - - - . .5,50 

236. — Purpura in fungating endocarditis - 555 

237. Discrete small pox - - - 561 

238. Conllueiit smallpox - - 561 

239. Se|itic dermatitis wrongly diagnosed 

as small-pox - - 562 
2K). Temperature chart 



241 . 



in prolonged 

inilucnza - 564 
in typhoid fever 565 

of iMediter- 

ranean fever 565 
in malignant 

endocarditis 
in lateral sinus 

thrombosis 
11 erysipelas 
I pernicious an- 



r>66 



:>(M 



Ilodgkin's 
.lisease - 
sarcoma 



LIST OF ILLUSTRATIONS 



IIG. 

•249 
250 



2G0 
201 



262 

2()3 



266 
267 
268 



. — Rectum oiKuing into virctlira - 
, — Malformations of rectum in male 
-2. — ,, ,, ,, female 

. — Temperature chart in cerebrospinal 
meningitis 

— .. .. rat-bite fever 
— Distribution of sensory nerves in 

the skin - - 
— Glove and stockini; ana>sthesia in 

peripheral neuritis 
, — Sensory effects of ulnar nerve 

division . . - . . 
— Sensory tracts in cord 
, — Ansesthesia from fracture of sacrum 

— .. myelitis 

— .. fracture of cervical 

spine 
— Sensory changes in syringomyelia 

— .. ,, tabes dorsalis - 
— Dissociative ana-sthesia from throm 

bosis of posterior inferior cere- 
bellar artery _ . _ . 

— Temperature chart in Kirkland"s 
disease - - 

— Speech centres 

— Splenic anemia - . . . 

— ^Temperature chart of typhus ending 
by lysis ----- 

— Temperature chart of typhus ending 
by crisis ----- 

— Enlarged liver and spleen in fun- 
gating endocarditis 

— Elastic fibres - - - 

— Temperature chart in lobar pneii- 



FIG. 

273 
274 



598 


278 




279 


605 


280 




281 


606 


282 




283 


606 


284 


607 


288 


608 




608 


289 


608 


290 


609 


291 


609 


292- 




294 



615 


297 


624 


298 


633 


299 




300 


638 


301 




302 


639 


303 




304 


640 




642 


305 




306. 



PAOE 

. — Calcareous concretions in sputum - 644 

. — Spondylitis deformans - - - 648 

. — Regions of the abdomen - - 659 

. — Idiopathic dilatation of stomach - 664 

.— „ „ bladder - 665 

. — Skiagram of chronic periostitis - 668 

. — ,. tuberculous dactylitis - 669 

. — .. syphilitic radius - - 669 

. — .. exostosis of femur - 670 

. — .. cnchondroma of hand 671 

. — .. sarcoma of tibia - 671 
-7. — .. ., radius 672-;j 
. — Carcinoma of stomach simulating 

aneurysm ----- 694 
. — Electrocardiogram in ■ paroxysmal 

tachycardia - - . - 703 

. — Cutaneous nerve-supply of the scalp 710 

. — Molluscum fibrosum - - - 711 

-3. — Segmental areas of the scalp - 712 
. — Areas of referred spinal pain and 

tenderness ----- 716 

. — Movements in intention tremor - 728 

. — - ., ataxy - - - 728 

. — Perforating ulcer of foot - - 736 

. — Diagram of a gummatous ulcer - 737 

. — .. a tuberculous ulcer - 737 

. — ., an ei)itheliomatous ulcer 737 

, — ,, a rodent iilcer - - 737 

, — Uric acid crystals - - - 741 

, — Varicose abdominal veins - 749 
— Renal growth extending into vena 

cava ------ 750 

— Small-pox eruption - - - 757 

— Ridging of nails after pneumonia - 769 



ILLUSTRATIONS, ALPH.^BETICALLY ARRANGED 



Abdomen, the regions of - - - 

Abdominal varicose veins 
Accoucheur's liand - - . - 

Achondroplasia . - - - - 

,. facies of - . - 

Acoumetcr, Politzer"s - - - - 

Acroiiicu:il\ . larirs of - - - - 

.\m(rli;i li\slol\ lira and coli 
Anaemia, iicrLiicious (tem])erature cliart) - 
,, splenic - - - . - 
.\na?sthesia from fracture of cervical spine 
,. injury to sacrum - 
myelitis 
syringomyelia 
thrombosis of post. inf. 
cerebellar artery 
Aivangioplastic infantilism 
Aiicinysm, large saccular (skiagram) 

obstructing the superior vena 
cava - - 

skiagram of - 
Angioneurotic oedema - - - . 

.Ankylostomiasis of the duodemun - 
.\nkylostomum duodenale 

,, ova of (2 figs.) 
Antrum, transillumination of - 
Aortic aneurysm obstructing the vena cava 
.\reas of referred spinal pain - 
.\rsenic, pigmentation of skin from - 



I'AUK 

659 
749 
3 
187 
237 
164 
237 

569 
633 
008 
608 
608 
609 

610 
190 
209 



180 
208 
716 



.\scaris lumbricoidcs. ovum of - 

Ataxy, movements in - 

Atelciosis ------ 

Athetotic hand - . . - - 

.Atiiny and jjaresis of colon, post-dysenteric 
.Atrophy in hand from cervical rib - 

muscular - - - . 

Auricular fibrillation (electrocardiogram) 
Bean in opsophagus (skiagram) 
Bilateral facial palsy - - - - 

homonymous hemianopsia (2 figs. 

temporal hemianopsia 
Bilharzia lucmatobia, ova of - 
Bismuth l)loekcd by epithelioma in nso- 
phagus (skiagram) 
,. in normal colon (skiagram) 

Bladilcr. idiopathic dilatation of 
Blood-film, method of making 
Botliridcephahis lalus. head of 
Brcincliial caMous f^ianil (skiagram) 
Brown-Si(|uar(l jiaialysis (2 diagrams) 
Bruits of mitral stenosis (6 diagrams) 
Csecimi. tuberculous - - - 

Calcareous concretions in phthisical sputum 
Calcium oxalate crystals 
Calcidus, renal (skiagram) 

ureteral (skiagram) - 

vesical (skiagram) 
t'ancrum oris - - . . . 



PAGE 

520 

728 

190 

132 

123 

508 

59 

486 

195 

493 

) 301 

300 

79 

196 
426 
665 

21 
519 
149 
497 

94 
458 
I 644 
423 
279 
455 
282 

74 



LIST OF ILLUSTRATIONS 



C'arboxylifeniofiloljiu, spectrum of - 

Carcinoma of bone (skiagram) 

coli with bismuth (skiauram) 
of liver, pyrexia in (chart) 
splenic Hexurc (skiagram) - 



320 

125 

stomach simulating aneurysm 694 



Caries of lumbar vertebra? (skiagram) - 460 

Caseous gland seen witli Ijronchoscope - 158 
Cerebrospinal meningitis (temperatme 

chart) ----- 591 

Cervical rib in adult (skiagram) 443 

„ child (skiaurain) - - 443 

,. spine, anasthcsia In mi injury to 608 

C'ervicobrachial plexus (iliagrani) - 507 

Chancre of lower lip - - - - 73 

Charcofs hip-joint (skiagram) - 350 

knee-joint . - - . 349 

Chest outlines ------ 167 

Cheyue-Stokes' l>reathing (diagram) - 107 

Cholcsterin crystals _ _ . _ 254. 
Cirrhosis, pyrexia in (temperature charts) 35, 371 

Claw-foot ------- 109 

Claw-hand - - - - - - 110 

Clubbed fingers in pulmonary stenosis - 111 

Coli bacilluria (tem])erature chart) - 456 

Colon, dropped (skiiigram) - - 426 

., in Hirschspiung's disease - - 127 

,, normal (skiagraiu) - - - 426 

Complex malaria (temperature chart) - 31 

Concretions in phthisical sputum - 644 

Confluent small-pox . . - - .-jei 

Congenital svi>hilis, faeies in (2 figs.) 234 

notched teeth (2 figs.) 234 

Connections of optic nerves and tracts - 300 

Constipation, habitual (diagram) - 122 

from lead poisoning (diagram) 124 

with miicomembranous colitis 124 



Contracture after a burn 
Dupuytren's 
Cretin, showing a 'frog-belly" - 
Cretinism . . . . , 

Crystals, calcium oxalate 

cholcsterin 

cysfin - . . . 

leufin - . - - 

plicnylglueosazonc 

triple ])liosi)hatc 

ly rosin 

uric acid 
Cutaneous nerve supply of the scalp 
Cyrtometrie tracings of various forms 

chest - - 

Cyst (hydatid) of Imig (skiagram) 
Cystin crystals - - . 

Dactylitis, tu^crculous (skiagram) 
Deal-porter's bursa 
Diphtheria, wristdrop riilluwiiig 
Diplopia, crossed double iinngcs 

hotnouyninus doulilc images 
Discrete smail-poN 
Dissociative aiinsthesiii Ironi I liiciinbosis 

posterior iulcrior ccrcbeiliir ;irlery 
Distribution of sensory uerxis jr] liic si 
Dropped colon (skiagliun) 
Dupuytren's contracture 
Dwarfism, riekelv 
Dysclie/.ia 

Dvstrophia adiposogenilalis 
Keliinricoecal booklets 
l-;i:islii- tibr<'s from spuluru 
l';iectiocar<liograni oraurjeuhir lilirilhili 
cstmsvstclcs 



142 
142 
233 
189 
423 
254 
161 
333 
262 
524 
333 
741 
710 



161 
660 



616 
605 
426 
I 1-2 



r.vGi; 
Electrocardiogram of heart-block (2 figs.) 83 
paroxysmal tachy- 
cardia - - 703 
Emphysematous chest outline - 167 
Enchondroma of hand (skiagram) - - 671 
Endocarditis, fungating, enlarged liver and 

spleen in - - 640 

(temperature chart) 566 

KpitheJiiiiuMtiJus ulcer (diagram) - - 737 

l-a-ysipijiis (tiuipcrature chart) - - 568 

ExopiitliaJMiic goitre, faeies of - - 236 

pigmentation of skin 

in - - - 527 

Exostosis of femur (skiagram) - - 670 

Extrasystoles (electrocardiogram) - - 544 

Face, head, and neck, sensory areas of 

(4 diagrams) - - _ . _ 44,s 

Facial paralysis (4 figs.) - 491, 492 

bilateral - 49;> 

from syphilis - 541 

Faeies of achondroplasia - 237 

acromegaly - . . . 237 

congenital syphilis (2 figs.) 234 

exophthalmic goitre - - 23*> 

familial lenticular degeneration 23H 

locomotor ataxy - - - 23(i 

a Mongolian idiot (2 figs.) - 23H 

myxu-iUrna (2 figs.) - 38 

myasthenic (2 ligs.) - - 235 

myopathic (2 figs.) - - - 235 

paralysis agitans - - - 236 

Familial lenticular degeneration, faeies of 238 

Favus ------_ 246 

Fibrosis of left lung, chest outline - 167 

Fingers, pads on (2 figs.) - - - 347 

Flint's murmur ----- 95 

' Frog-belly ' in a cretin - - - - 223 

Gall-stones (skiagram) - - - . 327 

Gallon's whi.stlc ----- 105 

Glands, malignant, left supraclavicular - 49 
' Glove and stocking ' anaesthesia in peri- 
pheral neuritis ----- 

Gonococcal arthritis (temperature chart) 
Gout, acute (temperature chart) 

chronic - . . . . 

„ (skiagram) 
Gummatous ulcer (diagram) - 
HuMuatin, acid, spectrum of - 

in alkaline solution, spectrum of 80 
Hirmoglobin, re<luced, spectrum of - - 80 
Hand. the. in tetany - . . 3 
in niyxiedcma - 38 
Heart block, electrocardiogram of (2 figs.) 83 
incoiuplete, polygraph trac- 
ing of - " - - 545 
polygraph tracing of - .546 
Ileberdeu's node's ----- .•}43 

Ileiuialrophy of face - . - - 494 

Henoch's purpura ----- 34.5 

Hirschsprung's disease ;J89 

colon iu 127 

Hodgkin's di.seasc ----- 377 

(temperaliirr cliinl) - ,570 

Hooklets, hydatid 49 

Hour-glass stonuich (skiagram) 268 

Hydatid cyst of lung (skiiigram) - 291 

booklets 49 

Hyperncplironia palieul (2 ligs.) 1.08 
ll\ piitlicriiiia ill lualignaiit caclicxia (tem- 

pcialuic chart) 312 
Willi iiiilral stenosis (Iciii- 

pciatiiie (hart) 311 



LIST OP ILLUSTRATIONS 



pa(;e 

Idiopathic dilatation of llic bladder - 6G5 

colon - - 389 

stomach - 664 

Infantile ])aralysis ----- 59 

Infantilism, anangioplastic - 190 

,, pituitary - - - 189 

Influenza, prolonijed (temperature cliart) 564 

Inteutiiiii Irciiiipr, rnovemeuts in - - 728 

Ki(hic\ , liil.( I. iilous (sl<iayrain) - 280 

Kirl^laiid's ihsease (tcmpeiature chart) - 615 

Larynx with tooth-plate impacted in - 195 
Lateral sinus thrombosis (temperature 

chart) ----- .567 

Leprosy, nodular - - 

,, peripheral neuritis in - 
Lencin crystals . . . - 

Lencomelaiiodcmiia. sypliiliHe (2 figs.) 
Leuka'inia (tenipciature chart) 

Lobar piuunKinia (tcin|)cratMre chart) 642 

Lordosis, myopathic - - - - 156 

Luml)ar caries (skiagram) - - - 460 

Lunil>osacral plexus (diaijram) - 500 

iMacular syphilides - - _ - 383 

Malaria, double tertian (temperature chart) 30 

,, chronic (temperature chart) - 31 

,, quartan (temperature chart) 29 

„ (|UOtitlian (temperature chart) 30 

„ tertian (temperature chart) . . 28 

Malformations of rectimi (4 figs.) - - 586 

Malignant endocardititis (temperature chart) 566 

cachexia (tem])erature chart) - 312 

,, left supraclavicular glands - 49 

Mediterranean fever (temperature chart) 565 

Meige's disease (2 figs.) - - - 411, 414 

Meningocele of face - - - . 230 

Metha-mrglobin, spectrum of - 80 

Miculicz's syndrome - - - 25 

Milrov's dis'iMM- (•_> fios.) - - . 411, 414 

Miners' i>h(lii-.is (ski:mram) - - - 159 

iMitral stenosis, diagram of bruits of - - 94 

,, „ (temperature chart) - - 311 

Molluscum fibrosimi, early - - 711 

Mongolian idiot, facies of a (2 figs.) - 238 

Mongolism (2 figs.) - - - - 190 

:\Iorbus ctrriUeus, pulmonary stenosis 157 

Movements in ataxy . - - - 728 

„ intention tremor - 728 

Mucous cast of intestine - - - 398 

Muscular atrophy - - - 59 

Myasthcni.' laciei (2 ligs.) - 235 

Myelitis, ana-stlicsia from - 608 

Myoi)atliic lacics (2 figs.) - - 235 

lordosis _ _ - - 155 
Myxci'dema, facies before and during (2 

_^ M^-) - - - - 234 

facies in (2 figs.) - - 38 

hands in - - - - 38 

Nails, ridged after pneumonia - - - 769 

Nod\dar leprosy ----- 404 

Notched teeth in congenital syphilis (2 figs.) 234 
Ocular muscles, double images in paralysis 

of ------- 177 

(Esophagus blocked by a bean (skiagram) 195 
idio])atliic dilatation of (skia- 
gram) - - - - 198 

., stenosis of (skiagram) 197 

OiJtic nerves and tracts, connections of - 300 

Osteitis deformans (2 figs.) - - - 155 

O.steo-arthropatliy. pulmonary (2 ligs.) - 351 

Osteogenesis impcrlccta - - - - 187 

Oxyhajmoglobin, spectrum of - - 80 

Pad.? on fingers (2 figs.) - - - - 347 



PAGi; 

Paralysis agitans, facies of - • - 236 

facial (4 figs.) - - 491, 492 

infantile - - - - 59 

of internal rectus - - 541 

of right serratus magnus - 506 

Volkmann's - . . - 14] 

Pellagra (temperature chart) 

Perforating ulcer of foot 

Periostitis, chronic (skiagram) 66K 

Peripheral neuritis, 'glove and stocking' 

anaesthesia in - 60(i 

in leprosy - - ,50.") 

Pernicious ana'uiia (temperature chart) - 56i> 

Peroneal palsy. Tooth's (2 figs.) - - 60 

PlicTivliiliiicsa/.onc crvstals - - - 262 

Phthisis, mottling of the hmg in (skiagram) lO.T 

Pigeon-chest outline - . - . 167 

Pigmentation from arsenic - - - 529 

in exophthalmic goitre 527 

Pituitary infantilism - . . - 189 

Pnemnonia (skiagram) - - - - 289 

with empyema (temperature 

chart) - - . . 160 
ridging of nails after 769 
Politzer's acoumeter - - - 164 
Polygra])h tracing of heart-block - - 546 
..of incomplete heart- 
block - - - 54.-, 
., of ventricular extra- 
systole - - 547 
Progeria --.-.. 190 
Pseudoleukamia infantum - - 37 
Ptosis and healed gumma of lace - - .541 
Pulmonary osteoarthropathy (2 figs.) - 351 
Pulsus bisferiens - - - - . 550 
Purpura in fungating endocarditis - 555 
Pyelogra|)hy (skiagram) - - - - 356 
Pyopneumothorax (skiagram) - - 531 
Hat liiti- fcyer (temperature chart) - 598 
Haynauds disease, fingers - - 257 
,, local asphyxia - - 256 
Rectum, malformations of (4 figs.) - 586 
Reflex centres in spinal cord - - - 518 
Regions of the abdomen - - - - 659 
Relapsing fever (temperature chart ) - 27 
Renal calciUus (skiagram) - - 279 
,, growth into vena cava - - - 750 
Rheumatoid arthritis, acute - - - 342 
,, hands in (skia- 
gram) - 342 
(temperature chart) 341 
transparency of bones 



(skiagram) 

Rickety chest outline - - - - 
,, dwarfism - - - - 

Ridging of nails after pneumonia - 
Rigors and pyrexia from lateral sinus 

thrombosis (temperatiu'e chart) 
RodcTit ulcer, diagram of - - - 

Sacrum, anasthcsia from injury to - 
Salicylates in acute rheumatism, effects^of 
(temperatme chart) - - - - 

Sarcini ventriculi - - 
Sarcoma of lung (skiagram) - 
radius (skiagram 
(temperature chart) 
of til)ia (skiagram) 
Seal]), cutaneous nerve supply of 

segmental areas of - - - 

Sensory areas of face, head, and neck 
(4 diagrams) - - - - 

disturbances in tabes - 



344 
167 
186 
769 

507 
737 
608 



- 338 
241 

- 105 
i figs. I 672, 673 

- 570 

- (>71 

- 710 



448 
6(»il 



LIST OK ILLUSTRATIONS 



TACK 

Seii.'ory olTccts of ulnar luivc divisioii - (■,{)(; 
localization in spinal cortl - - 518 
nerves in the skin, distribution of ()()5 
traets in cord - - - _ 007 
Septic dermatitis wrongly diaijnosed small- 
pox - - - - - - - -.f.2 

Serratus niaKUUs paralysis - - . .-;()(; 
Skiagram of aneurysm - - . . (,3.-, 
Iiean in the u'sopliajius- - lo.'j 
bismntli blocked by epitheli- 
oma in (esophajius l!)f> 
in dropped colon - 420 
in normal colon - -1.2(i 
eareinoma of bone - - ],'52 
coli with bisnmth 

enema - - 12(1 

of s])lenie llexiire- I2.j 

stomaeli - - 200 

[)ylorie 270 

cardiospasm - - - . 19^ 

caseous bronchial jrland - 149 

cervical rib in adult - 4J.;{ 

child - - 443 

Charcot's hip-joint - - 350 

chronic frout - _ 345 

periostitis - - 0O8 

dropped and dilated stomach 318 

enchondroma of hand - - 071 

exostosis of femur - - - 070 

^'a 1 1 -stones - - - _ ;j27 

hands in acute rheumatoid 

arthritis - - . . 342 

hour-glass stomach - 2(>8 

hydatid cyst of lung - - 29] 

large thynms gland - 41 9 

leatlier-liottlc ston)aeli 27() 
lobar pneumonia 
lumbar caries 
lung in ])htliisis 

,, sarcoma - - lo.^ 

miner's phthisis - l-,9 

normal stomach 24.";. 20il 

perl.isteal sarcoma of tibia " 7i'\ 

pyelography - - . ;;.-,() 

pyopneumolhoraN ^ . r,:U 

renal calculus - . . 27!) 

saccular aneurysm - 2()!» 

sarcoma of radius (4 figs.) 072, (i7;i 

tibia - (171 
■ spine ' on os calcis 
stenosis of the lesophagu 
syphilitic radius - 
sliowing transpareiu-v of In 
Jn rheiUTiatoid arlhiilis 
Ihymcis gland crdarged 
tuberculous daelylilis 

,. kidney 

ureteral calculus '• 
v<'sical c'aleulus 
Sinall-po\. corilluenl 
.liser.le 
eruption 
>pcelral absorption bands 

V'O'lrimi or aei.l lia-irialirj HO 

'■•"■'"'^^yl'''- tilobin 80 

'licmalui in alkaline solution 80 

niell,a-n,og|,,lMn - , 80 

oxyha-moglobin - 80 

reduced ha-moglobin - 80 

,'• . "r<-l)ilin - - 80 
pceeli centres - - . . _ ,.., , 
pinal cord, rellex eenlres in - - . ,'Xh 



28!t 
4<iO 

io:j 



41.0 
1!»7 
(i(i!) 

.■(44 
H!) 
(iO!) 
280 



-.57 



Spinal cord, sensory localization in - 518 

„ pain referred, areas of - - - 710 

■ Spine ' on os calcis - - . - 440 

Splenic ana;mia - - . (;;j;j 

Spondylitis deformans - - - - (i48 

Sputum, elastic libres in - - - - 042 

Still's disease -----_ 377 

Stomach, eareinoma of (skiagram) - - 20!) 

dilfuse (skiagram) 270 

pyloric (skiagram) 270 

dropi)ed and dilated (skiagram) ;il8 

idiopathic dilatation of - - (J64 

normal (skiagram) - - 243, 20!) 

.Sy])hilides, macular ----- ^s!! 

Syphilis, congenital, faeics in (2 ligs.) - 234 

uotehed teeth in (2 figs.) 234 

facial paral.Nsis from - - - 541 

|)tosis and paralysis from (Migs.) 541 

Syphilitic leucomelauodermia (2 ligs.) - 528 

„ radius (skiagram) - - - (i(j9 

Syringomyelia, ana;sthcsia from - - 009 

Syringomyelic claw-hand - - - 110 

Tabes dorsalis, faeics of - - - 230 

„ sensory changes in 009 

Tachycardia, paroxysmal (electiocajilio- 

gram) -----. 703 

Ticnia mediocanellata, head of - - 519 

,, solium, head of (2 ligs.) - - 5i<) 

ovum of - - - - 520 

Temperature chart in carcinoma of li\er, 

pyrexia of - - 320 
cerebrospinal menin- 
gitis - - - 591 
cirrhosis, pvrexia of 

3.5, 371 
coli baeilluria - 450 
erysipelas - - 508 

gonococcal arthritis 338 
gout, acute - - 33!) 

Hodgkin's disease - 570 
hyi)othermia in ma- 

ligiumt cachexia 312 
hypotherntia with 

mitral stenosis - 311 

iidluenza, prolonged 504 

Kirkland's disease 015 

• . .. leuka'inia - - 25 

!> „ malaria, chronic - 31 

,. ., complex - 31 

.. double Icr- 

liau 30 

(pi.artau 29 

ipjolidiau - .'iO 

!. !, .. Iciliau - 28 

>. ,. malignaid cudoear 

ilitis - 500 

„ ,, .Mcdilerrauc.-m fever 50.5 

" >, pellagra - 223 

pernicious auaiuia 5(i9 

,, pneumonia willi 

empyema - - KiO 

,. pneumonia, lobar - (i42 

pya-mia - 507 

rat-bile fever 598 

rela|)siiig fever - 27 

.. .. I'hcumatism, acute, 

eireel ofsalieylales 3.38 

:. .. rheumatoid arllirilis 341 

<-ase of sarcoma - .570 

typhoid fever - 505 

I \phus fever ending 

bv crisis (i39 



LIST OF ILLUSTRATIONS 



TerajH-niturc i-liarr in typluis lever cixliiis 

by lysis - - - 

Tetany, tlie liaiiil in 
Thymus ■.land cnlaificd (skia<.n-am) 
Tiiiie relations iit food in lar^e 

(diaiirani) - - - - 

Tooth-plate iinpaetcd in larynx 
Tootirs |)eroneal palsy (2 figs.) 
Transillumination of the antrum 
Triehnccphalus dispar in the colon 

., ovum of 
Triple (ihosphate crystals 
Tuliere\dons ea-eimi - 

kidney (skiagram) 
iilcer (diagram) 
Tuniny-fork with foot-jjicce 
Tyjihoid fever (temperature chart) - 
Typhus fever ending by crisis (temperalui 
'chart) 



I'AGE 

038 
3 

n9 

1 23 
19.5 



458 
280 



of 



Typhus fever ending by lysis (tempcrati 

chart) ----"' 
Tvrosln crystals - 
lUcer of foot, perforating 
T 'leers, typical (diagrams) 
Ulnar nerve division, sensory elTcet 
Ureteral calculus (skiagram) - 
Uric acid crystals - 
Urobilin, spectrum of 
Varicose abdominal veins 
Vena cava obstructed by aortic aneurysm 

superior, obstructed by aneurysm 
Ve'iitrieu'lar extrasystole (polygraph tracing) 
Vesical calculus (skiagram) 
Visceroiitosis - - - 
Volkmann's paralysis 
Xon .Jaksch's disease 
Whip-worms in the colon 
Wrist-drop after di])htlieria 



638 
333 



(iOO 
45.5 



208 
1;58 
547 

282 



AN INDEX OF 

DIFFERENTIAL DIAGNOSIS 
OF MAIN SYMPTOMS 



ACCENTUATION OF HEART SOUNDS.— It may be that, without cardiac bruit, 
me or other of tlie heart sounds is much louder tlian it ouglit to be. Such accentuation 
eneraily has important clinical significance. It is the first sound that is likely to be accen- 
uated or prolonged at the impulse ; whilst in the second right, or second and third left 
ntcrcostal spaces close to the sternum, it is the second sound that is likely to be accentuated 
athcr than the first. It is very unusual to find the first sound accentuated at the base 
ir the second sound at the impulse, unless there is at the same time still greater accen- 
uation of the first sound at the impulse, and of the second sound at the base respectively, 
lence the three conditions under which accentuation of a cardiac sound becomes clinically 
mportant are: (1) When the second sound is unduly loud in Ihc second right intercostal 
pace close to the sternum ; (2) When there is accentuation of the second sound ivith 
nadimum of inleuaiti/ in the second or third left intercostal space close to the sternum ; 
:j) When there /.v accentuationof the first sound icith maximum intensiti/ at or near the impulse. 

Accentuation of the second sound witli maximum intensity in the second right 
ntercostal space close to the sternum nearly always indicates that the systemic hlood- 
)ressurc is above the normal. The latter can only be determined with certainty by actual 
neasuremcnt of Ihe systemic blood-pressure instrumentally. The causes of the increase 
vill probably be one or other of the following : — 

-Irtf. — Even liealthy jjcrsons over fifty begin to show sliglit increase of Blood- 
RKSSuitK (p. 81) : and their aortic second sound begins to get louder than the first. 

Arteriosclerosis or granular kidney. — These can be discussed together, because it 
s extremely dillieult to tell where the one ends and the other begins. In both there is 
ardiae liyperlniphy, increase in the blood-i)ressiire, prolongation of the first soimd at 
he impulse, possibly a blowing systolic bruit there, a ringing or clanging aortic second 
;oun(l, albuinimiria. a tendency to heart failure as time goes on, with all its concomitant 
lyniptoms, and albuminuric retinitis. It is sometimes stated that the accentuation of 
he aortic second sound is due to local atheroma ; but this is inaccurate, for atheroma 
)y itself, though it may easily produce an aortic systolic bruit, does not accentuate the 
iccond soun(^: and when in the second right intercostal space there is a soft systolic bruit 
•eplacing the lirst sound, and a clanging second somul, the former indictites atheroma of 
he aortic valves, and the latter arteriosclerosis. These two absolutely <listinct vascular 
esions often coincide in the same j)atient. atheroma affecting the aorta, and the coronary 
md cerebral arliries, whilst arteriosclerosis affects the middle-sized arteries, especially 
)f the splanchnic area. There is often extensive visceral arteriosclerosis when the radiid 
irtcry docs iiol IVcl alini)rm:d to the fingers. 

Accentuation of the second sound with maximum intensity in the second or 
third left intercostal space close to llu- slcrnum. generally spoken of as acccnl nation 
f the pulmonary second sound, indicates a higher pressutc lliaii I heir sliould be in Ihe 

(ulmonary circulation, except in children, in wliorn it is not imicoii ii lo liiicl llir pul- 

iionary second sound normally nuich louder than the aortic. The most important cause 
)f pathological aeccntMalion of the pulmonary second sound is disease of Ihe mitral valve ; 
t,occurs more markedly willi milial slenosis than with inilral regurgitation. It may 
ionietimcs he a niaikcd fcaluic oi Ihr lallcf. ulicllici' iliic lo oiLiaiiic cliaiiges In llic mitral 
n 1 



•2 ACCENTUATION OP HEART SOUNDS 

valve itself, or secondary to dihitatioii of the otherwise normal orifice as the result of heart 
failure from aortic disease, niyocanlial diueneration, arteriosclerosis, or granular kidney. 
Sometimes, instead of accentuation of the pulmonary second sound, the latter may be 
reduplicated ; the significance of its reduplication is identical with that of its accentuation, 
the probable reason for the reduplication being that when the pressure in the jjulmonary 
circulation is relatively very much above the normal, the pulmonary semilunar valves 
close sooner than the aortic, the first part of the reduplicated second sound being due to 
closure of the pulmonary valves, whilst its second part is due to closure of the aortic valves. 
The cause of an accentuated or reduplicated pulmonary second sound will generally be 
obvious if the other cardiac physical signs are observed carefully ; one way in which it 
may have particular significance is in distinguishing between old and recent changes in 
the mitral valve ; when, for instance, a systolic and mid-diastolic bruit at the impulse are 
due to recent endocarditis which may jiosslbly clear up, there is very much less accentua- 
tion of the pulmonary second sound than there would be if the same bruits were due to 
mitral stenosis and regurgitation due to old lil)rotic changes. The greater the accentuation 
of the |)ulmonary second sound, the greater the mitral leakage or obstruction. 

Accentuation of the first sound at the impulse may have one or other of two 
entirely different characters ; it may be an accentuation of very short duration, difficult 
to describe in words, though obvious enough when heard, and often spoken of as a 
■ slapping ' first sound at the impulse : this is one of the most characteristic physical 
signs in many cases of mitral stenosis. It may occur when there is neither a presystolic 
nor a mid-diastolic bruit, though even when there is a bruit the slapping character of the 
first sound is still to be distinguished. When there is failure of compensation in a mitral 
case, the driving power of the heart may become so feeble that bruits are no longer audible, 
and the heart's action is quite irregular ; in such cases, the occurrence of this slapping 
character of the first sound, clearly audible here and there in an otherwise tumbling 
rhythm, is highly suggestive of mitral stenosis. 

The second variety of accentuation of the first sound at the impulse consists in its 
being very much longer tlian it ought to be — a marked prolongation of the first sound 
as distinct from there being any bruit. This prolongation is obvious enough when heard. 
It indicates that there is considerable hyi)ertro])hy of the left ventricle, and therefore, 
in the absence of bruits, nearly always points to a high blood-pressure such as results from 
either arteriosclerosis, granular kidney, or the two combined ; it is repeatedly met with 
in cases in which there is accentuation of the aortic second sound at the same time. In 
a ])crson of middle age or over, in whom there is a prolonged first sound at the impulse 
— sometimes spoken of as a • lumpy ' first sound — and a clanging aortic second sound, 
with or without Albuminuria (p. 11), a diagnosis of arteriosclerosis or of granular kidney 
is very probably correct, and instrinnental determination of the blood-pressure will 
generally sliow that it has risen from the normal 120-150 mm. Hg to something between 
l.S() and 300 mm. Hg, or even more. 

It is noteworthy that transient accentuation of the first sound at the impulse may 
occur in nervous young patients examined while their hearts are acting rapidly ; it vanishes 
in a few minutes when the patient becomes less nervous and the heart slower. The 
phenomenon is common in connection with life insurance examinations. Herbert French. 

ACCOUCHEUR'S HAND is seen most characteristically in tetany (Fig. 1), though 
it may also occur in a few cases of other spasmodic neuro-museular affections such as 
<itlictr>sis. In a typical case, the attitude of the fingers is almost pathognomonic. There 
is full extension of all tlie fingers and of the thumb at the interphalangeal joints, the four 
fino-ers are adducted firmly towards the middle finger, so as to form a cone, they are semi- 
flexed at the metacarpo-phalangeal joints, and the thumb is strongly adducted and opposed 
to the cone of which the middle finger forms the apex, or else into the palm of the hand. 
The spasmodic muscular contraction seldom ceases here, but generally affects the rest of 
the arm also, the wrist being flexed and abducted towards the ulnar side. The elbov/^ is 
flexed to a right angle, and the arm rotated inward and adducted so as to lie in contact 
with the trunk. The affection is symmetrical. The feet and ankles are apt to show 
similar spasmodic contractions, the ankle being fidly nlantar-flexed, the toes and the distal 
iialt of the feet rotated inward, the knees extended rigidly, and generally the thighs also. 




ACETONURIA 3 

Tlie contractions may be limited to tlie liands and feet — the so-called carpo-pedal spasm 
— especially in the tetany of young children suffering from rickets or from gastro-intestinal 
disorder such as diarrhoea. AVhen adults are affected, the symptoms spread from the 
limbs to the trunk, the whole body being kept rigidly extended, the paroxysms lasting 
from a few minutes to many hours, and recurring for^ays. weeks, or even months. So 
far as the tetany itself is concerned recovery is 
invariable, though the patient may sometimes 
succumb to tlie associated malady, tetany itself 
being generally not a primary disease but a com- 
plication of gastric ulcer, gastrectasis, colitis, 
intestinal fermentation or putrefaction, thyroidec- 
tomy, or jircgnancy. The diagnosis is seldom 

dillicult. - 

One remarkable feature of the case is that 
in the intervals between the spasms, if the upper 
ami is grasped firmly between the observer's two 

hands, and the pressure maintained, the hand and wrist may be forthwith sent into the 
typical spasm, a sign described as Trousseau's. If the cheek close to the front of the ear 
is percussed gently but sharply from above downwards, the different groups of muscles 
supplied by the branches of the pes anserinus of the seventh nerve can be made to 
twitch successively — Chvostek"s sign. The muscles of the limbs often show altered 
electrical reactions in that, though still responding to faradism, with galvanism .\.C.C. is 
greater than K.C.C. — Erb's sign. Herbert Freiieli. 

ACETONURIA denotes the occurrence of acetone in the urine in amounts to be 
(lilcitcd by (iiiliiuiry clinical tests. In ])ractice the lalxiratory method of distilling a 
(|uantity of urine to get a concentrated solution of any acetone that may be present takes 
too long, and yet without distillation it is dillicult to apply the iodoform test for acetone. 
An easier and more useful plan is Legal's nitroprussidc test, or Rothera's modification of it. 
Legal's test consists in taking 5 c.c. of urine in a test-tube, adding a few drops of liquor 
sodic, then a few drops of fresh sodium nitroprussidc solution, and finally acidifying with 
strong acetic acid. The li(|Uor soda- causes no change of colour, or at most an opalescence 
from the prccii)itation of j)hosphates ; the sodium nitroprussidc produces a reddish-brown 
colour in almost all urines owing to the presence of creatinine : if the red colour is due to 
creatinine only it is discharged on adding acetic acid, whereas when acetone is present 
the red deepens into a rich burgundy that is unmistakable. Kothera's modification of this 
test consists in adding a few dro|)s of fresh nilroprusside solution to .5 c.c. r)f urine, li(|U()r 
anun(>ni;c till the tnixlure is decidedly alkaline, and llieii ainnioniuin sulphate cryslals 
in excess : as the solution bcc(jiiies saturated willi llie latter, a colour like that ol' polassiuni 
permanganate develops if acetone is present, the maximum being reached in about fifteen 
minutes. 

.\cetone is often ass{)ciatcd with diaeetic acid, oxybutyric acid, and ainido-oxybulyric 
acid ; the rietcction of these, 'however, affords no clinical inl'orinalion that is not alTorded 
by the acetone alone, so that it generally sullices to tesi for the latter, and jxissibly for 
diaeetic acid also. The tests for the butyric acids are clilliculf. When these subslances 
are being proilueed, the patient is said to be suffering from miilosis. the result of unnatural 
metabolism, .\cetonuria is indeed the chief i>ractical evitlenee of acidosis. It occurs in 
the most extreme degree in certain cases of diabetes mellilus ; from the point of view of 
prognosis all cases of glycosuria may be di\idcd broadly into two classes, namely, those 
with, and those without, acetomnia. 'I'lie same patient may. of course, l)e jiassing acetone 
in his urine at one time and not at another : the |)rognosis is always graver, howevir. when 
acetone is present, for it is tlic acidosis that causes the serious results of diahctis and 
glycosuria. .\ |)atient witimut acelonuria is in no immediate danger of enma. wliiiias. 
when acetone is present as well as sugar, coma may siiperx iiie at aii\ linic. Uroadly 
speaking, once glycosuria has been diagnosed, it is more iiiip(jrlarit to list the urine for 
acetone from time to time than it is for sugar, and thai t ic:it iiiriil wliieli ir(hiees the 

acetone to a miniinum is, ijciierally speaking, lining most g I, wliati\ir (|uaiililies of 

sugar may be passed. 



4 ACETOXURIA 

Acetontiria may occur, however, without glycosuria ; even a healtliy person who 
is starved oi^ carbohydrate food is apt to pass acetone and diacetic acid in the urine. Tliis 
explains why it is that acetonuria occurs in such conditions as gastric ulcer : gastric carci- 
noma ; gastrectasis : oesophageal stenosis : intestinal obstruction : cachexia, whether 
tuberculous, malignant, syphilitic or malarial : in cases of persistent vomiting of pregnancy : 
ura>mia ; severe migraine ; infantile diarrhoea and vomiting : cyclical vomiting of children 
(p. 765) ; and probably in many other conditions in which there is either actual or virtual 
starvation. The same applies to surgical operations under ansestheties — the patient is 
often starved beforehand, and may then be persistently sick afterwards : almost all patients 
who have been under a general anicsthetic for any length of time have acetonuria. and in 
some the acidosis increases instead of being transient, this being to a large extent, perhaps, 
the pathology of so-called delayed chloroform poisoning. It may also result from gross 
intracranial lesions, especially those of an inflammatory nature ; thus, acetonuria may 
be pronounced even as early as the first two or three days in acute epidemic cerebro- 
spinal meningitis. 

The chief importance of acetonuria therefore from a diagnostic point of view lies, 
not so much in distinguishing one disease from another, as in detecting the existence of 
acidosis. The importance of this from the point of view of prophylaxis and treatment 
will be obvious when it is remembered that acidosis does not occur until the liver and tissues 
have lost their glycogen, and that glycogen storage depends largely upon the ingestion 
of carbohydrates either by the mouth, the rectum, or hj^DOdermically. Herbert Freiieli. 

ACIDOSIS.— (See Acetonuria, p. 3.) 

ACROPARiCSTHESIA.— (See Pain in the Extrejiitv, Upper, p. 442.) 

ALBUMINURIA. — This term is used to denote the passage in the urine of proteid 
that is coagulablc on boiling. More than one substance is included in this sense, and there 
are varying proportions of albumin and globulin in different cases. So variable may be 
the relative amounts of these, not only in different diseases, but also in different cases of 
the same disease, and in the same patient at different times, that little useful clinical infor- 
mation is to be obtained by dealing with them separately, at any rate so far as present 
knowledge goes. Nucleo-albumin (p. 424) comes in quite a different category. 

Although numbers of tests for albumin have been devised and advocated, for clinical 
purposes there is little need to trouble about more than the two common ones, namely 
the acetic acid and boiling, and the cold nitric acid tests. It is true that each of these has 
fallacies ; but the latter are not common to both, and therefore if there is doubt in the 
interpretation of one of the two tests, it can be confirmed or otherwise by the other. More 
delicate tests exist, but there is such a thing as too great delicacy in a clinical method. 
One does not want to find albumin in minute traces where it does not matter ; and it 
seldom matters until its amount is sufficient to give both the common tests. 

The Acetic Acid and Boiling Test. — A test-tube three parts full of urine — cleared 
by filtration if need be — is held by its lower end whilst its upper part is heated carefully 
to boiling point. It is best not to add any acetic acid before boiling unless the specimen 
is distinctly alkaline, in which case it may be just acidulated with a drop of acetic acid. 
After boiling, the tube should be held in a good surface-light against a dark background, 
such as the sleeve of one's coat : any opalescence will be obvious, and there may be a dense 
white cloud. Except in rare cases of Bence-Jones albumosuria (p. 16), this will be due 
to one or more of three things, namely, calcium and magnesium phosphate, calcium car- 
bonate, or coagulated albumin. One. two. or more drops of acetic acid solution (B.P.) arc 
now added : if the cloud disappears entirely, quickly, and at once, it was due to earthy 
phosphates, and no albumin is present : if it disappears entireh- but with brisk efferves- 
cence, the latter is due to calcium carbonates amongst the phosphates, and no albumin is 
present ; if, on the other hand, the cloud clears up but partially, or remains imaltered, or 
actually increases and becomes more flocculent, albumin is almost certainly present. There 
is only one serious fallacy remaining, and that is in regard to nucleo-proteid : this is preci- 
pitated by acetic acid, and it is possible for a cloud of phosphates to be cleared up by the 
latter and yet for a faint cloud of nucleo-proteid to come down in the place of the phosphates 
in such a way as to suggest that the original cloud was not wholly soluble in the acid, and 



ALBUMINURIA 5 

therefore that albumin is present when it is not. There are three ways of obviating this 
soiirce of fallacy : the first is to add a single drop of dilute non-fuming nitric acid to the 
suspicious cloud that remains after adding the acetic acid ; if it is due to albumin it will 
persist or even increase, whilst if it is due to nucleo-proteid the nitric acid will disperse 
it ; the second is to perform the cold nitric acid test for albumin as described below — 
nucleo-proteid will not give a definite localized white ring with it ; and thirdly, a control 
test may be done, acetic acid being added to another specimen of the urine without boiling, 
and the cloud due to any nucleo-proteid present compared with the cloud in the acidulated 
and boiled specimen. 

Heller's Cold Nitric Acid Test. — About an inch and a half of urine is poured into 
a test-tube, the latter is held much inclined, and colourless nitric acid is allowed to flow 
gently down the side until about one-third as much as the urine has been added. The 
nitric acid is heavier than urine and goes to the bottom : if albumin is present a white 
ring lorms at the jimction of the two fluids. Some prefer to pour the nitric acid into the 
test-tube first, and then add the urine with a pipette. It is important not to shake the 
tube, or the nitric acid and urine will mix and there will be no definite junction line between 
them. Fuming nitric acid must be avoided because the nitrous oxide fumes decompose 
the urea and the resultant bubbles mix the fluids ; sometimes there is bubbling even when 
the nitric acid is colourless, in which case this is due tc CO.. set free from carbonates. The 
test is very delicate ; if any large quantity of albumin is present, the ring appears at once ; 
it there is only a trace, the white ring may not appear for a little, and the tube should be 
set aside and looked at again in a few minutes. Broadly speaking it takes three minutes 
for it to develop when the amount of albumin is 1 part in 30,000. This test is open to 
more fallacies, however, than the acetic acid and boiling test, so that it should not be 
trusted to alone unless it is negative. In concentrated urines it is common to get a dark- 
brown, reddish-brown, or violet brown ring of colour at the junction ; this is nothing to 
do witli albumin : it is generally most marked in eases of Indicanuria (p. 314). White 
rings, more or less like that due to albumin, may also be due to any of the following : — 

1. Resin. — If the patient is taking copaiba or other similar drug, enough of the resin 
may be excreted in the urine to form a diffuse white cloud above the nitric acid. This 
fallacy is best avoided by bearing it in mind and checking the nitric acid test by the heat 
test ; this latter safeguard applies to all cases of suspected albuminuria. 

2. Albumoses. — These generally occur in association with albumin ; should they 
occur alone the ring will disappear with warming, to reappear with cooling, and there will 
be no cloud with the heat test. 

3. Tinici-.JoiHs'.i Albnntnse. — This occurs without albumin, gives a white ring with 
nitric acid that disappears on warming, to reapjiear on cooling ; with the heat test, a 
dense cloud appears about GO^ C, to disappear on further heating to boiling-point (p. l(i). 

t. Xiirlro-iilhiimiii. — The ring with this is not in contact with the nitric acid, but 
higluT up, and diffuse ; it may be a real difficulty in diagnosis from albumin, for it is also 
precipitated by acetic acid, and may therefore give a haze with the boiling test (see above). 

5. I'raJcs. — These may form a cloud near the nitric acid if the urine is very concen- 
trated ; the cloud will disappear on gentle warming, to reappear on cooling, so that it 
mav also be mistaken for albumose ; the fallacy may be avoided by diluting the urine- 
with plain water before the nitric acid test is employed. 

0. Urea Xilrale. — If the urine contains a large percentage of urea a crystalline deposit 
of urea nitrate may form at the junction ; as a rule the crystalline nature of the ring is 
obvious on inspcelioii ; but in case of doubt the urine should be dilulcd and Ihc (est 
repeated. 

It docs not niatler whicn lest is most relied upon when Ihc result is lugalivc ; bul 
before the positive deduction that a urine contains albumin is drawn, both the acetic acid 
and boiling, and ttie cold nitric acid tests, should be positive. 

In aiiiving al a diagnosis of the precise cause of .'dliuiniiiiiiia in an\- gi\(ii ease, it is 
rssciiliiil Ihul a mirroscnpiral ci'diiiiiHitioii of the iiiitrijiiildliud ilcjiiisit (i(i)n Ihc mine slioiilil 
hr made. Whatever else niay be ff)und, the first (piestioii to be answered is : Are renal 
tul)e-easts present as well as albiunin. or not r All cases of albumiimria may be divided 
into two iimin ^'voups, namely : (I) Crisis nilli loinl liihi-iasis : (II) Cases liilhijut rnuil 
liihe-(iis'\. 



6 ALBUMINURIA 

Renal Tube-casts. — AVhen one speaks of renal tube-casts, however, one has to bear 
in mind tliat modern methods of centiifugahzing with electrically-driven machinery have 
reached such perfection that hardly anything that a specimen of urine contains escapes 
detection ; technique has become almost too perfect ; for when clinical methods become 
too delicate they begin to lose some of their clinical value. The result, in connection with 
casts, is that even in a great many normal urines an occasional renal tube-cast and an 
occasional red blood corpuscle are found ; therefore when one speaks of cases of "' albumin- 
uria witn tube-casts." one means "" witli enough renal tube-casts to be pathological." The 
observer learns from experience to know when the ' occasional ' tube-cast is inside or 
outside the normal limits. More than one examination may be rccjuired, and the urine 
should be as fresh as possible, for casts disintegrate on standing, especially in hot weather 
and in alkaline urines. 

Renal tube-casts are of various sorts (Plate I), and a certain amount of help can be 
derived from a knowledge of the particular kinds of casts present in a given case. Their 
matrix or foundation is a structureless material whose origin is obscure, thougli thought 
to be due to some kind of proteid coagulation. Sometimes the casts consist of this 
structureless matrix only, and according as they are then less or more highly retractile, 
they are spoken of as hyaline casts or ivaxy casts respectively. The hyaline is commoner 
than the waxy, but neither is characteristic of any particular disease. Embedded in the 
hyaline matrix there may be various substances or structures ; and according to the main 
features of the embedded substances the casts receive different descriptive names. If 
renal epithelial cells predominate, the cast is an epithelial cast : if leueocj-tes or pus corpuscles, 
a leucoci/tic cast ; if red blood corpuscles, a blood cast : if bacteria, bacterial casts ; if fat 
globules, probably derived from degenerated renal cells or leucocytes, fatit/ casts ; if non- 
fatty granular debris, granular casts. It is not at all imcommon to find a long cast which 
in one part is simply hyaline, at one end is granular, and at the other epithelial — a mixed 
cast. Upon the whole one may say that the hyaline cast occurs in all forms of nephritic 
conditions, whether acute or chronic ; that epithelial and leucoc\-tic easts indicate active 
catarrh ; that granular easts tend to occur along with epithelial casts, but that when they 
occur alone or in association with hyaline casts they are evidence of at least less acute 
mischief than are epithelial casts ; whilst fatty casts come between the two. Blood casts 
may occur in almost any variety of renal ha?morrhage. and by themselves they are not 
evidence of inflammation, though in association with other easts they indicate very acute 
inflammatory changes. 

I. -ALBUMINURIA WITH RENAL TUBE-CASTS. 

When it nas been decided that there are a jiathologieal lumiber of renal tube casts 
as well as albumin in the urine, it is almost certain that there is an inflammatory lesion 
of the kidney. The next step in the diagnosis is to decide by microscopical examination 
whether pus is present also ; in other words, the cases may be subdivided into two main 
sub-groups, namely : (A) Albuminuria -cvith renal tube-casts tcithout obiious ])us : and 
(li) Albuminuria with renal tube casts and obvious pus. There are border-line cases in 
which leucocytes are present in excess, and yet not in sufficient numbers to constitute 
pus ; other points about such a case will generally lead one to decide whether it come- 
in the apyurie or in the ])yuric group. The differential diagnosis of the latter is discussed 
under Pviria (p. 'i'i). so that it only remains lure tt) discuss : — 

(.1) The Differential Diagnosis of Albuminuria lvHIi Tube-easts without Obvious Pus. — 
The causes of tliis condition may be classilied as folk)ws : — 

1. The Various Forms of Bright's Disease: — 

(a) .\ primary acute nephritis. 

(b) \n acute exacerbation upon an underlying chronic ne|)hritis. 

(c) Chronic nephritis of young ]K(iple : (i) Arising out of a known attack of 

acute nephritis : (ii) Arising without any known prexious attack of acute 
nephritis. 

((/) Chronic nephritis of old ])CO])le : (i) cirrhosis of tlie kidneys ; (ii) Arterio- 
sclerosis. 

((') Cystic disease of llie kidneys. 
•2. Nephritis of Pregnancy. 



PLATE I 



RENAL TUBE CASTS 



4. 




/•- 





A. Il.vniiiiorasis; B, Wnxy casts: c Myaliiic MLst coritiiiuintr siniill crystals of raloiiim oxiihitc; D, Hloucl cints; 
E, A Icuc'or-ytc init ; F, Hpitlidiiil wists; G, <in""ilur casts; H, Futty ciiats. 



iMii:x III- iiiMiXosis— 7'« jure />. 



ALBUMINURIA 7 

3. Chronic Ascending Nephritis, leadino; to scarred contracted kidneys, the result of 

{(!} ()l)structii)n to urine outflow by : — 
(i) Urethral stenosis, 
(ii) Enlarged prostate, 
(iii) Displacement of the womb. 
■ (iv) Fibromyonia. ovarian cyst, or other |)elvic tiunour. 
(v) Pregnancies. 

(vi) Undue mobility of the kidney and kinkinw of the ureter, 
(vii) Rarities, such as abdominal aneurysm obstructing a ureter. 
(h) Irritation ascending from the pelvis of the kidney, the result especially of 
calculus, but also sometimes of chronic tuberculous lesions, 

4, Lardaceous Disease of the Kidneys. 

'>. Infarction of the Kidneys, esi)ecially when the result of embolism in cases of 
fungatiiig endocarditis : Imt also due to thrombosis, as in some blood diseases, 
(i. Thrombosis i>f tlie inferior vena cava involving the renal veins. 
T. New Growth of the Kidney, some cases. 

In many cases the diagnosis soon becomes obvious, but in some there may be great 
dilliculty. The two following may serve to illustrate how such difficulties may arise : 

A patient of middle age, who had not been strong for a long time, began to suffer from 
tt'dema of the ankles, which increased rapidly and spread to her legs, thighs, genital organs, 
and back. Within a few days her abdomen began to swell, and she began to pass very 
little water, the colour of blood. Upon examination the urine had a sp. gr. of 1030. wa.s 
loaded with albumin and blood, and microscopically there was an abundance of red 
corpuscles, renal epithelial cells, leucocytes, and epithelial, fatty, granular, and blood 
casts, without ])us, crystals, or bacteria. It seemed almost obvious that she must be 
suffering frf)m acute Bright's disease : but there was no oedema of the eyelids, and there 
was delinite enlargement of the left supraclavicular lymphatic gland ; the discovery of 
the latter led to a very careful examination for malignant disease ; and a latent and <|uitc 
unsuspected carc'inoma of the rectum was foimd. 'I'lu- diagnosis was carcinoma recti, 
secondary dcjiosits in the retroperitoneal glands, obstruction and thrombosis of the inferior 
vena cava and of the renal veins, with consequent albumiimria, hematuria, and renal 
tube-casts from as])liyxial nephritis, sinnilating acute Bright's disease. 

Another case was that of a girl of !(!, suffering from increasing ana-mia, shortness of 
breath, (edema of her ankles and lac c, and slight pyrexia. The heart was a little enlarged, 
and there were soft systolic bruits that were regarded as secondary to the anaemia. The 
urine contained blood and albumin, willi renal e|)itlielial cells and tube-casts in abundance. 
Ascites developed, with increasing general (edema : there were also retinal ha'morrhages 
and neuro-retinitis. 'I'he diagnosis of acute nephritis, however, was only in small degree 
correct : for she was really suffering from maliiinani endocarditis of a subacute type, 
the nephritis being due to iidccted crTilioli of llie Uidney pnidueing intlammatory changes 
around nuiUipic renal itilarcts. 

'I'hese cases will serve to show how it nia\ be impossible to arrive at a correct diagnosis 
excci)t by thorough examination of all the systems, by watching the case carefullw and 
by repeating the fidl systemic examination at intervals. We will now deal witli I lie 
headings in the abo\c table in their reversed order. 

If there is New Growth in a kidney the munber of renal lube-easts is likely to be 
small ; sooner or later a microscopic fragment of new growth may be detected in the ccntri- 
fugali/cd urinary deposit. .Mbuminuria will not be extreme unless the renal veins and 
the inferior vena cava become invohcd (/•'/;,'. ;iO f. p. 7.50). the same ap|)lying also to the 
nedema of the legs and trunk : h:iiiial uiia is liUclx to occur at iidervals, the attacks being 
separated by many weeks soniclinies. and liiing r(laliv<'l\ painless : there may be an in- 
creasing renal tumour: cystoscopic cxaminal ion may show blood-slaincd mine (see Philc 
.Vr. Fifi. .1, p. -jHti) coming from one ureter only ; and finally, when suspicion of new growth 
has been aroused, laparotomy may be indicated and the diagnosis conlirmed thereby. 

Thrombosis of the Renal Veins and Inferior Vena Cava has been rchrred to 
above as a conditioTi that may simulate acute nephritis. I'oinis lo lay stress on in nrri\ ing 
at the diagnosis are : (I) To make a Ncrv careful and svstcmatic examination, including 



8 ALBUMINURIA 

that of rectum and vaiiina, in order not to miss anything, sueli as some latent growtli. wliose 
secondary deposits are obstructing the veins ; (2) To enquire carefully into the history 
— many cases of inferior vena caval thrombosis are due to extension vipwards i'rom iliac 
or saphenous clots, in which case there will nearly always have been swelling of one leg 
only to start with, followed later by extension to the back and to the other leg : (3) To 
note that although the oedema of the legs and back may be extreme, there is a delinite 
upper level to it and no swelling of the eyelids or scalp : and (4) To note that if there are 
any distended or varicose veins upon the abdominal wall (see Veins, Varicose Abdominal, 
Fig. 303, p. 749), the current in them has become reversed — to being from below 
upwards instead of from above downwards. 

Infarction of the Kidneys may be either embolic or thrombotic. The commonest 
cause of embolic renal infarction is fungating endocarditis. Each embolus gives rise to 
the sudden appearance of blood in the urine which may have contained none previously, 
or to increase in any existent hasmaturia ; there may or may not have been a sudden pain 
in the back at the same time. Around each infarct acute nephritis develops, so that in 
some cases all the characters of the latter malady may be superposed upon those of the 
fungating endocarditis. If the patient is already known to have heart disease the diagnosis 
is easy enough ; the difliculties arise in cases in which, notwithstanding the endocarditis 
there is no bruit. If fimgating endocarditis is suspected, the points that confirm the 
diagnosis arc those mentioned on p. 34. 

Thrombotic infarcts are less severe in their effects ; they may produce no haematuria 
at all, and the albuminuria may be slight, and unaccompanied by tube-casts. They 
generally arise in cachetic conditions, or in blood diseases such as leukaemia or pernicious 
anaemia, in whieli cases the diagnosis will be arrived at on other grounds, albuminuria 
not being the ]>nMiiineut feature of the ease. 

Lardaceous Disease of the Kidneys used to be common in the days of septic 
surgery, but it is uncommon now. It is a risky diagnosis to make, therefore, unless there 
is some obvious cause for it, such as long-standing suppuration in association with a .spinal, 
hip-joint, or empyema sinus, bronchiectasis, phthisis with cavitation, or the like ; or clear 
evidence of tertiary syphilis with cachexia. There is nothing characteristic about the 
urine. In the earlier stages there may be but a trace of albumin in an otherwise normal 
urine ; later, the albumin increases and it may reach very large amounts, such as 20 parts 
per 1000, casts being very few in proportion, the total amount of urine increased, its colour 
pale, and its sp. gr. low — 1005 to 1012 : later still, possibly as the result of superposed 
nephritis, the amount of urine falls until only a few ounces may be passed each day, of 
high colour and sp. gr. 1020 to 1035, loaded with albumin, and now containing hvaline, 
waxy, granular, fatty, and epithelial casts. Lardaceous easts may or may not occur, but 
they are not diagnostic, for they have also been found in cases of nephritis without lardaceous 
disease. Indeed, the diagnosis of lardaceous kidney resolves itself into one of guesswork 
in a case in which there has been prolonged suppuration or severe syphilis to give rise to 
it, and in which there may be smooth firm enlargement of the liver, moderate enlargement 
of tne spleen, and more or less severe diarrhoea, to indicate corresponding lardaceous 
change in the other organs that are generally affected at the same time as the kidnevs. 

Chronic Ascending Nephritis arises from precisely the same causes as acute ascending 
nephritis or surgical kidney, and probably results from recurrent focal inflammations 
which heal, with the result that, in the course of months or years, the kidneys are con- 
\erted into a mass of irregular fibrotic scars which together produce the same local and 
general changes and effects as are found in cases of ordinary red granular contracted kidney. 
It is important to bear in mind that any cause of prolonged obstruction to the urine 
outflow may cause granular kidney with albuminuria, without pus but with easts, in a 
pale abundant urine of low specific gravity. The diagnosis will generally be ob\ious 
when the obstruction is due to urethral stricture ; it is more apt to be overlooked in 
other cases, though if one bears in mind the causes mentioned in the list above, the 
methods of diagnosis will generally be clear. One would only mention in particular that 
uterine timiours or displacements are a very common cause for slight albimiinuria and a 
few renal tube-casts in women ; and that in men of sixty and over enlargement of the 
prostate causes a precisely similar condition long before Ihere is any delinite pyuria. 

Pregnancy Nephritis is sometimes spoken of as though it were an altogether different 



ALBUMINURIA 9 

thing to nepluitis of the Brighfs disease type in general. I do not subscribe to this view, 
I hold that Bright's disease has many different causes and many different types. It may 
be due to scarlet fever, in which case it is very possibly streptococcal ; it may be due to 
pneumonia or empyema, in which cases it may be pneumococcal ; it may be due to 
various other micro-organisms ; it occurs in some cases of cholera, and in severe secondary 
syphilis ; it is frequent in malaria, especially the quartan type ; it may be due to chemical 
substances such as turpentine, cantharides, or oxalic acid ; it very often seems to come 
on from no known cause at all, though in such cases there must be a microbial or other 
cause that is not discovered : it may be due to pregnancy, in which case it is ascribed to 
unknown toxins. In all these cases the t>-pes of reaction on the part of the kidney are 
similar, and one can only regard pregnancy nephritis as a variety of non-suppurative 
ne])liritis in general. Very likely it is only a matter of degree whether it is non-suppurative 
or merges into the type in which there is pyuria as well as albuminuria — pyelitis of preg- 
nancy. Pregnancy may cause a primary acute nephritis, which may recover either com- 
pletely, or but partially and persist as chronic nephritis : or may seem to recover when in 
reality it is merely latent, or even slowly and insidiously progressive ; it may produce 
what seems to be a primary acute nephritis which is really but an exacerbation superposed 
upon a chronic nephritis that has been unsuspected ; and very possibly it may produce 
nejihritic changes which are not associated with definite symptoms at the time, but which 
ultimately result in what is spoken of as chronic interstitial nephritis. When, therefore, 
alliuminuria with renal tube-casts, but without pyuria, occurs during pregnancy, it matters 
little what name is given to the condition, provided it is realized that just the same difli- 
culties offer themselves here as in Bright's disease in general, in arriving at a conclusion 
as to wlietlier the renal lesion is acute, chronic, or acute on chronic. 

Various Forms of Bright's Disease. — Of all these, the hardest to diagnose with 
certainty is pih/iiiri/ acute iiephrilis in the adult. The majority of adult cases that are 
labelled acute J3right"s disease are really suffering, not from primary acute nephritis, but 
from an acute exacerbation upon the top of already existent but possibly latent chronic 
nephritis. The dilliculty is to arrive at the diagnosis between these two, particularly 
since many of the jxiints mentioned in text -books as occurring in acute nephritis are really 
due, not to thi' acute attack, but to the subacute or chronic i-enal lesion which has, until 
then, been unsuspected. 

The best exam|)l(s of |)rimary acute tiejiliritis are to be seen in eases that are already 
under observation for some other disease, notably scarlet fever or lobar pneumonia. Some- 
times the onset of the nephritis is indicated by general (cdema, especially of the eyelids 
and lace, ankles, genital organs, and loins ; but it cannot be insisted upon too sti'ongly 
thai irdema is not esseiilial. many cases of acute nephritis having no o-dema at all, especi- 
ally if the patient is already in bed when the kidney inllammation begins, as in scarlatina 
cases. If the urine were not examined the renal lesion would often escape recognition 
altogether : and there can be no df)ubl that many cases of primary acute nciihritis do 
escape rccognilion in this way, coming under observation later when they present symptoms 
of chronic Tvpliritis, or an acute exacerbation on chronic nephritis. 

The essential point in the diagnosis is urine examination. According to the severity 
of the nephritis there will be more or less diminution in the total daily (piantity : it is 
eoinnion for less than 20 oz. to be passed in the t W(iit\ -lour hours, and often the amount 
falls to 10 oz.. .> oz.. or even to none at all for a wliiU'. The spccilic gravity is raised to 
lO'J.j. KKiO, or even to lO:!"., but ranl\ to 10 10. The naction is generally acid at first, 
but it soon beconics alkaline on standing. The colour is extremely variable, according 
as little or much bloo<l is present : sometimes it is almost normal or merely that of a con- 
centrated urine ; mori' often llieie is some tinging with blood, varying from bright red 
to brownish, brown, brown-black, or to that peculiar blackish tint which is descrilied as 
smoky. There is a getieral cloudiness of the spe<'imen, and on standing it deposits a heavy 
sediriicnt which ofl<ii has a dark brownish tint owing to the phosphates carrying the blood 
pigmenl with thcin. Microscopically, the ccntrifugalized deposit consists jjartly of 
amorphous debris due to earthy phosphates, and to the disintegration of cells anil tube- 
easls : and one expects to lind an abundance of red corpuscles, renal epithelial cells, \ari- 
able numbers of epithelial, fatty, granular, hvaline. an<l blood -casts, an excess of Iciieocyles, 
an occasional cr\stal of calcinin omiImIc or uric acid, and irregular gnmular iriasscs which 



10 ALBUMINURIA 

are not defluitcly tutic-casts. It is noteworthy, however, that in the very aeiite stages 
there may be no tube-casts, though shed renal epithelial cells are abundant : in such a 
case tube-casts will show themselves in a few days. It is important that each specimen 
should be examined as fresh as possible, owing to the tendency of casts and cells to dis- 
integrate on standing. In addition to red corpuscles there is often much free lia^moglobin ; 
the tincture of guaiacum test will be positive, and the spectroscope will show the bands 
of oxyhaemoglobin or of metha?moglobin. Coaguhible proteid is generally present in 
abundance, the proportions of globulin and albumin varying greatly, but together amount- 
ing to anything between 2 and 20 parts per thousand — often about 15 parts per thousand 
at first, rapidly dropping to less after tlie first few days of treatment, until at the end of 
from a fortnight to a month it may be 1 part per thousand or less, or even absent 
altogether. In a few cases, however, tliere is very little coagulable proteid but an 
abundance of albumose, so that the boiling test gives but a faint cloud, whilst the nitric 
acid test yields a dense white ring, soluble on warming, to reappear on cooling. There 
is generally an excess of nucleo-proteid also. The urea, chlorides, and phosphates all 
fall below the normal totals, though their percentages may be increased if the urine is 
very concentrated. 

With this condition of urine there will be little doubt as to the presence of acute 
nephritis ; the only question then is whether it is primary, or an exacerbation upon chronic 
nephritis. The former is probable if it is known that the urine was free from albumin up 
to the time of the attack, if the patient is known to have suffered recently from scarlet 
fever, pneumonia, diphtheria, secondary syphilis, or some other similar fever ; if the heart 
is of normal size and its sounds natural, the blood-pressure natural, and the retina" healthy. 
It may be that the patient himself may have been exposed to scarlatinal infection, and 
without having had the rash may develop nephritis ; the association of peeling of the 
skin, or recent sore throat with enlarged glands in the neck, or otitis media, might suggest 
the diagnosis in these mild cases of scarlatina, though sometimes acute nephritis in a child 
may be the sole evidence of the disease. The course of the malady will also assist the 
diagnosis ; the albuminuria of primary acute nephritis may clear up entirely in from a 
fortnight to six weeks, though in unfavourable cases it persists and chronic nephritis 
develops out of the acute. If, on the other hand, it is found that, in a case of ajjparently 
recent acute nephritis, with general oedema, hoematuria and the other urinary changes 
described above, there is cardiac hypertrophy, with a prolonged lumpy first soimd at the 
impulse, a ringing aortic second sound, a blood-pressure of more than 150 mm. Hg, and 
possibly albuminuric retinitis, the probability is that the acute nephritis is not primary, 
but an acute exacerbation of an unsuspected chronic nephritis. There is often a history 
of former scarlet fever or of syphilis in such cases ; the patients may be of any age, from 
childhood to past middle life. If the patient survives, one or other of two conditions 
usually results : either the albuminuria, the scanty urine, and the tube-casts persist, whilst 
the patient remains waterlogged until the end comes in a few weeks or months, or else 
the acute exacerbation subsides and the clinical characters of chronic nephritis remain. 

Some of these cases, but by no means all of them, are exampjles of primary acute 
nephritis, persisting and becoming chronic. It must, however, always be very difficult, 
and indeed almost a matter of opinion in many cases, to decide whether a patient is suffering 
from a chronic nephritis which is the result of a primary acute nephritis that has not 
cleared up, or from a chronic nephritis which was jiresent but unrecognized before an acute 
exacerbation drew attention to it ; my own view is that many cases in which young adults 
seem to develop acute nephritis from no more definite cause than exposure to damp or 
cold, are really examples of acute on chronic, and not of primary acute, Bright's disease. 
The albuminuria in these cases does not clear up, and it is a mistake to restrict the diet 
or the daily occupation after the acute exacerbation has subsided. In spite of the per- 
sistence of albuminuria, these patients do best if they are given iron and allowed to go 
about their ordinary avocations ; they have diseased kidneys, and they will not live many 
years, but there is no need to adopt treatment which constantly reminds them of the fact. 
As the acute exacerbation subsides, the amount of urine rises rapidly to 60 or 70 oz. or 
more per diem, and remains increased even after all oedema has passed away ; the specific 
gravity falls to 1012, 1010, or 1008 ; the albumin persists to the extent of anything between 
O'o and 8 parts per thousand ; blood is absent, though an occasional red corpuscle may 



' ALBUMINURIA U 

be .seen iiiKkr the microscope ; and there arc moderate numbers of hyaUne. granuhir 
or even fatty casts, with an occasional renal cjiithclial cell. 

It happens not infrequently that a young patient sufferino- from chronic iicpliritis 
comes under observation for shortness of breath, jialpitations, ana-mia, or for inflammation 
of one or other of the serous membranes, without ever having had any symptoms of acute 
nephritis at all. The kidneys that would be found in such cases differ from the granular 
contracted kidneys of older people in tliat they are pale instead of red. They are pale 
granular contracted kidneys, precisely similar to those which may result from a long 
antecedent acute nephritis that has not entirely cleared up. When they develop without 
any known preceding attack of acute nepliritis they have been referred to as Rose-Bradford 
kidneys. It is by no means impossible that they are really the result of a preceding acute 
nephritis which escaped recognition because there was no oedema to attract attention to 
the need for urine examination. The patient may be of any age, though generally between 
five and thirty-five. There may be no sign of anytliing wrong until acute uraemia, with 
convulsions, leads to rapid death. On the other hand, in a typical case, in addition to 
the urine changes mentioned above, one expects to find some of the following symptoms 
or signs ; /a great increase in the size of the left ventricle, as evidenced by displacement 
of the impulse downwards and outwards, even into the sixth left intercostal space below 
or outside the left nipple, with increase of the precordial impairment of resonance outwards 
to the left without corresponding increase u])wards or to the right ; a ringing second sound 
in the second right intercostal space close to the sternum, and a prolongation of the first 
sound at the impulse, or its replacement by a localized blowing systolic bruit ; more or 
less anicmia, sometimes very considerable and of the chlorotic type ; a maximum systolic 
blood-pressure, of 175 mm. Hg, or more, sometimes over 300 mm. Hg, even when the 
pulse feels comi)aratively soft to the finger : albiuninuric retinitis ; a tendency to hemor- 
rhages, especially to epistaxis ; headache : insomnia ; brcathlessness on exertion ; and 
inability to work with the usual energy, either mentally or physically. 

The chronic nepliritis of old people is diagnosed more often than it exists, if one under- 
stands by it tlie disease associated with small red graiudar contracted kidneys. On the 
other hand, the kidneys of most old people exhibit a certain amount of interstitial fibrosis, 
with occasional retention cysts and some granularity of the surface when the capsules 
are stripped off. without there being any material diminution in tlieir size. \Miere senile 
changes that are almost normal end and chronic interstitial nephritis begins, is difficult to 
determine. The same applies to arteriosclerosis and the renal changes associated with 
this. Some regard arteriosclerosis and chronic interstitial nephritis as essentially different 
maladies : others regard the arterial as secondary to the renal changes ; others hold thai 
arteriosclerosis leads to a variety of red granular kidney that is not the same as the red 
granular contracted kidney of chronic interstitial nephritis : whilst others again favour 
what seems a likely view, namely that arteriosclerosis and sclerosis of the kidneys botii 
have conmion eaiiscs. and that it is more or less an accident whether the |)aticnt, on post- 
mortem cxajiiinal ion. presents more arterial or more renal changes, or about tlie same 
degree of both. During life the differential diagnosis between them is sometimes impos- 
sible. In either case there will be a hypertro|)hied left ventricle, a loud lumjiy first sound, 
or a blowing systolic bruit, at the impulse, a markedly accentuated aortic second sound. 
a systolic blood-pressure somewhere between 150 and :520 mm. Hg. with a tendency to 
shortness of breath : giddiness, especially on sudden change of posture ; singing in the 
cars; dilliculty in concentration of mind ; and very ])ossibly cardiac symptoms. \ aryitig 
from a mere consciousness of the existence of the heart, to precortlial ])ain of varying 
severity, or even extreme heart -failure, with (edema of the legs, ascites, nutmeg liver, 
orthopnnea, and ])ulmonary congi'slion. In the latter case the great difiiculty will be lo 
decide whether the heart failure is due l<> |iiiniary renal or arterial, primary cardiac, or (o 
primary |)ulni()iiarv disease, and the only sure methods of deciding that there is a renal 
lesion are: tlie (liseover\- of more than an occasional granular an<i h\aliiie tube-cast in 
the in'ine ; the deti'ction of albuminuric retinal changes : and inslrumeiital determination 
that the blood-pressure is nnicli raised. Sometimes inllanunation of one of the serous 
membranes is the first syiiiploni : subacute or chronic peritonitis with ascites ; ])cricar- 
ditis : or pleuiilie eHiisidii. On llic other hand, the (jaticnt nuiy seem to have been in 
robust hcMllli iiiilil Ihc nalmc of llic ease is suggested by a sudden apoplectic seizure (\uv 



12 . ALBUMINURIA 

to cerebral haMnorrhage. In yet another group of cases the mahidy is discovered acci- 
dentally as the result of examination for lile insurance. It is not very uncommon to find 
glycosuria as well as albuminuria, the sugar occurring in a urine of normal specific gravity 
without any associated acetone or diacetie acid. The degree of albuminuria is very 
variable ; when tliere are signs of cardiac failure there may be oliguria with much albumin 
and not a very large munber of casts ; when there is no heart failure there is generally 
polyuria, the patient having to rise several times in the night, passing from 60 to 120 oz. 
of pale urine in twenty-four hours, of sp. gr. 1008 to 1012, often containing only a trace 
of albinnin. and even that not constantly ; there are intermediate cases in which the 
amount of albumin varies from 0-25 to 4 or 5 parts per thousand. Upon the whole one 
may say that, if the increased albuminuria due to heart failure on the one hand, or to a 
super-added acute attack of nephritis on the other, can be excluded, the more the disease 
approaches the type of red granular contracted kidney, the more likely is the albumin 
to be small in amount and intermittent : whilst the more the disease approaches in type 
to arteriosclerosis with renal changes on the one hand, or to pale granular contracted 
kidneys on the other, the greater will be the amount of albumin, if any is present at all. 
riiere will be tube-casts, chiefly granular and hyaline, most numerous with pale granular 
contracted kidneys, fewest with arteriosclerosis, and intermediate in numbers with red 
granular contracted kidneys. It need scarcely be added that the absence of albuminuria 
does not exclude arteriosclerosis : but we are here dealing only with cases in which albu- 
minuria occurs. 

Cystic Disease of the Kidneys is found in three entirely different types of patients, 
namely. (1) the new born, (2) the young, and (3) the elderly. In the new born the main 
symptom is abdominal distention, which may be so extreme as to have caused difficulty 
in delivery : the bilateral cystic tumours can be felt, and the diagnosis in such cases 
is not dillicult. Elinor degrees escape detection at birth, and it may be that several years 
elapse before the diagnosis is arrived at as the result of finding bilateral uneven renal 
tumours associated with the passage of abundant pale urine of low specific gravity con- 
taining traces of albumin, a few granular and hyaline tube-casts, and an occasional red 
corpuscle. Sometimes a sudden and severe attack of ha-maturia is the first symptom in 
the case. The discovery of bilateral irregular renal tumours is the clinching point in the 
diagnosis. In at least one case they were so large as to meet in the middle line, so that a 
loop of intestine that had passed between and behind them could not get out again, and 
the patient came under observation for acute intestinal obstruction. The third type of 
cystic disease of the kidneys occurs in old persons, and is but a variety of chronic intersti- 
tial nephritis in which the agglomeration of retention cysts has reached an extreme degree : 
the enlargement of the kidneys is then much less than it is in young persons, where the 
lesion is probably congenital ; the symptoms and urinary changes are precisely similar 
to those already described in cases of red granular contracted kidneys. 

(/?) Albuminuria ivith Renal Tube Casts and ivitfi Pus. — When pus is present in the 
urine along with albumin and renal tube-casts, the differential diagnosis resolves itself into 
that of pyuria that is partly or wholly of renal origin (see Pyuria, p. .574). It only remains 
to add : first, that it is not sufficient to rely upon the naked-eye characters of the urine, 
or upon chemical tests, in excluding minor degrees of pyuria ; microscopical examination 
of the centrifugalized deposit is essential, especially in the detection of acute pyelitis 
and pyelonephritis the result of coli-bacilluria in children, pregnant women, and others 
(p. 09) ; secondly, that the amount of albumin actually due to pus itself is small, so that 
if there is any measurable quantity of albumin present it indicates that the kidneys are 
themselves affected, this being further confirmed when easts are also found : and thirdly, 
tliat blood, like pus, is in itself responsible for relatively little albumin, so that wnen there 
is considerable albuminuria associated with blood, there is strong ground for believing 
that the albumin is by no means all due to the blood. The presence of very small quantities 
of blood does not assist the differential diagnosis of the cause of albuminuria so much as 
miglit be expected : much blood indicates that the cause is due to one or other of the 
conditions discussed under Hjematiria (p. 275). 



ALBUMINURIA 13 

II.- ALBUMINURIA WITHOUT TUBE-CASTS. 

Turning now to albuniinmia without tube-casts, one would enijjhasize the fact tliat 
more than one microscopical examination may be required, for if the urine is alkaline, 
or has stood for any length of time, casts, originally present, may have become unrecog- 
nizable ; besides which, even with definite nephritis, there may be very few casts at one 
time, many at another. This applies particularly to the very acute cases on the one hand 
and the very chronic on the other. Assuming that not more than a very occasional cast 
is found, the chief conclusion that can generally be drawn is that the albuminuria is not 
indicative of organic renal disease. The cases may then be subdivided into : (1) Those 
in luliich the urine presents some other definite abnormality besides albuminuria, especially 
a) pyuria. (6) ha;maturia. (e) haemoglobinuria, or (d) glycosuria ; (2) Those in ivhieh, 
■jaerc the albumin removed, the urine tcould be normal. 

i . These cases need not be discussed further here : the differential diagnosis will be 
found under Pyuri.\, H-ematluia, H^emoglobinlria, and Glycosuria respectively. 
j 2. These are clinically of importance in that, until the absence of casts Jias been 
[letermined, the absence of organic renal changes cannot be concluded. Even when casts 
ire absent, a trace or a small amount of albumin may be the first evidence in elderlv 
jcrsons of enlargement of the prostate, chronic interstitial nephritis, or arteriosclerosis : 
)r in younger persons of chronic ascending nephritis, the result of such things as former 
;onorrha-a, repeated pregnancies, uterine prolapse or other displacement, chronic vesical 
atarrh. or urethral stricture. The chronic effects on the kidneys of interference with the 
irine outflow are apt to be overlooked, though if they are borne in mind they are generally 
asy of diagnosis. 

The following arc a number of other conditions which may cause slight degrees of 
dbuininuria without tube-casts, but which are obvious, or else diagnosed by other signs 
hat arc discussed elsewhere : burns, scalds, chronic alcoholism, cirrhosis of the liver, 
liabetes mellitus, exophthalmic goitre, gout, lead-poisoning, mumps, secondary syphilis, 
norphinism, mercurialism. vasomotor neuroses such as Raynaud's disease or angioneurotic 
edema, obstruction to the vena <!ava inferior by thrombosis or by external tumours, the 
)rcssure of considerable ascites, ovarian cysts or solid tumours, pernicious ana-mia. 
lotlgkin's disease or lynipliadcnoma. lymphosarcoma, lymphatic or splenomcdullary 
euka'inia. splenic anaemia, pcinpliigus, [jhospliorus poisoning, chronic arsenical ])oisoning, 
)rcgn:»icy, severe ana>mia the result of syphililic. malarial, nialignanl, tuberculous, or 
hthisical cachexia, ankylostomiasis, or infection with otlici- parasites such as Itollirio- 
ephiilus latus or Trichina spiralis. 

There remain three other groujis of conditions in which albumimiria and its dilTercntial 
liagnosis are often important, and these are: (1) Febrile eonditions : (■>) Heart-failure 
onditions : and (:!) so-called ■ I'hi/siologicar albuminuria of adolescence. 

Febrile Conditions. — In nearly every fever there is some cloudy swelling of the 
larcnchyma Tif various viscera, especially the kidneys ; consetpiently most fevers may 
ometimcs be associated with albuminuria, and, broadly s[)eaking, the higher the patient's 
empcrature the greater is the liability to it. The amount of albumin present is generally 
lot great. We need not enumerate all the various fevers in this coimcxion. SulJice it 
o say that iilbumiiuiria is r(lati\ely conunon in scarlatina, diphtheria, variola, erysipelas, 
)yrexial i)hthisis. cholera, dysentery, Weil's disea.se. severe malaria, and yellow fever : 
lot so common in lobar pneumonia. bidncho[)neunionia. tvphoid fever, and empyema : 
ind relatively uncommon in other febrile conditions, such as acute rheumatism, inllucnza, 
neningitis, measles, German measles, follicular tonsillitis, and .so on. The albiMiiinuria 
nay, of course, be already present in a person who develops an inUrciirrciil \'r\ii- : Ihe 
liagnosis then depends upon considerations menlioncd above. 

If, on the other hand, the albuinimu-ia is known to have developed coincidently with 
he febrile illness, the chief point to decide will be whether it indicates actual nephritis 
)r not. .Many consider there is an essential difference between ■ febrile albumimiria " 
ind actual nephritis. This may or may not be so, but it is extremely dillieull to be sure 
if the distinction clinically. It may be urged that to take scarlet lexer as an example - 
he albuminuria of the lirst few days is ■ febrile.' whilst that of Ihe second or third week 
s ' nephritic' .Vs a niiitter of fact, in not a few cases in which death has occurred in the 



14 ALBUMINURIA 1 

liist week the ' febrile " albuminuria has been associated with larr mottled acute nephritic 
kidneys, even where there has been no oedema, no hiematuria, .id no very large numbers 
of renal tube-casts. Probably there are all degrees of acute nephritis, from very slight 
and transient, to very severe and possibly fatal ; and it is a mistake to try and make a 
distinction in kind. The great majority of cases of albimiinuria during fever recover 
completely ; some seem to recover but come under observation years later with pale 
granular contracted kidneys ; others die during the acute attack. The degree of albumin- 
uria is not a direct measure of the renal changes unless the amount of albumin is large ; 
a small amount of albumin does not necessarily indicate trivial nephritis. Absence of 
oedema is the rule. Microscopical examination of the centrifugalized urinary deposit is 
essential : the more the renal epithelial cells, red corpuscles. leucoc>-tes. and various renal 
tube-casts, the more conclusively can some degree of actual nephritis be diagnosed. 

When doubt lies between scarlatina and measles or German measles, or between 
diphtheria and other forms of sore throat, the existence of albuminuria sometimes assists 
in arriving at the diagnosis of scarlatina in the one case or of diphtheria in the other. 

In pneumonia, albuminuria has become much less frequent since blistering wutli 
cantharides has gone out of fashion in treating this disease. 

Heart-failure Conditions. — The right side of the heart may fail owing to many 
different causes, wliieh may be arranged under four main headings, as follows : (ri) Valvular 
disease : {b) Obstructive lung affections ; (c) Myocardial affections ; (rf) Granular kidneys 
and other liigh blood-pressure conditions. Each of these main headings has many sub- 
headings (see Orthopncea, p. 418). Any one of them may result in albuminuria, though 
the amount of the latter is extremely variable, some cases of severe heart failure exhibiting 
no albiuninuria at all, whilst others may have as much as 10 parts per 1000, or more. 

The first step in the differential diagnosis is to exclude primary renal conditions by 
negative microscopical examination of the centrifugalized urine deposit for casts, examin- 
ation of the retime, and exact determination of the blood-pressure. Curiously, even with 
feeble irregular pulses, such as are found in jjanting cases of mitral stenosis, the blood- 
])ressure is considerably higher than normal, doubtless owing to partial asphj-xia ; so 
that merely finding a systolic blood-pressure of 150 or 160 mm. Hg is no proof of granular 
kidney or arteriosclerosis ; sometimes, however, the reading is as high as 200, 250, 300, 
or even :J20 mm. Hg, and then the diagnosis of one or other of the latter is almost certain. 
If renal and arteriosclerotic conditions can be excluded, the diagnosis lies between 
the other three main groups. The cardiac bruits, the history of growing pains, chorea, 
or acute rheiunatism, the youth of the jiatient, the family history of heart disease or 
rheumatic fever, the association of other rheumatic affections such as recurrent tonsillitis 
subcutaneous nodules, or erythema, will often serve to point to primary vahular disease ; 
in older patients, esiiecially in men between forty and fifty, there may be aortic disease 
and a history of syphilis and not of acute rheumatism. In severe heart failure in children 
imder puberty, the result of mechanical dillieulty with the circulation, an adherent peri- 
cardium is generally found, and clinically, t!ie heart is large out of jjroportion to the general 
physical signs. 

When there is a definite history of recurrent winter cough in an elderly person, with 
a hyper- resonant and over-expanded chest, the likelihood of emphysema and hronchilis 
will at once suggest itself. Similarly fibroid lung, or fibroid hmg and bronchiectas^is, as a 
cause of heart failure and albuminuria, only needs mentioning, the diagnosis generally 
being obvious from tlic physical signs, the clubbed fingers, and in the bronchiectatic cases, 
the abundant intermittent, and frequently foul, expectoration. 

Myocardial affections, such as fibroid, fatty, or primary alcoholic heart, are generally 
diagnosed by guessing at them when other causes of heart failure can be excluded. The 
jjatients are generally middle-aged, shortness of breath on exertion, precordial pain and 
even angina pectoris occupying a prominent position amongst their cardiac symptoms ; 
there may or may not be a high blood-pressure, the albuminuria is not associated with 
renal tube-easts, there is often no cardiac bruit, or at most a more or less localized blowing 
systolic bruit at the impulse ; at the same time the heart is clearly enlarged, and it may 
be beating rapidly and irregularly ; there may be a history of syphilis or of chronic 
alcoholism : the jjatient may be ver>- stout in the fatty, though generally not so in the 
fibroid, cases. There may be a history, either of an extremely sedentary life upon the 



ALBUMOSURIA 15 

one hand, or of over-use of the lieart by strenuous hard physical work — as a blacksmith, 
an athlete, and so forth — on the other. Electro-eardiographic tracings may be required 
in determining the nature of the heart lesion. 

Needless to say, the exact nature of the cardiac lesion remains obscure or uncertain 
in many of tliese cases, many a patient who really has mitral stenosis being regarded during 
life as suffering from chronic bronchitis and emphysema, and so on. 

' Physiological ' Albuminuria. — Finally, we come to the albuminuria of apiiarently 
healthy males and females lietween the ages of fifteen and thirty. The condition was 
little known until medical examinations at schools, or for life insurance, or for the 
services became common. It has received a number of names, of which the following 
are some : " accidental,' " essential,' " postural,' " cyclic,' " orthostatic,' ' intermittent,' 
' physiological,' " functional," • orthotic,' albuminuria, Pavy's disease, albuminuria " of 
adolescence ' or "of puberty.' It derives its chief importance from the fact that 
young males who suffer from it may be rejected for life insurance or for the services, from 
the fear that they have some form of nephritis. A similar condition occurs in females of 
a similar age. but it is detected less often than in males because one has less occasion to 
examine the urines of healthy girls than is the case with boys and youths. Collier and 
others have tlirown much light upon the nature of the affection by their investigations 
upon the urines of rowing men. It is found that tlie urine passed just before a boat-race 
being free from albumin, that voided immediately after is generally loaded with it. A 
few hours later this albuminuria is gone again. Now university oarsmen are, u])on the 
whole, long lived, hence this recurrent albuminuria cannot matter in them ; and the same 
applies to the albuminuria of many adolescents. A prominent feature of such a case is 
that the urine first voided in the morning is quite normal, wliilst that passed later in the 
day may contain anything from a trace to five parts per thousand of albumin ; the more 
the youth has exerted himself physically by walking or otherwise, and the more he has 
exposed himself to cold, for instance during a train journey to the city on a winter's day, 
or in a cold ijath. the greater is the liaijility to this unimportant but possibly alarming 
albumimiria. Some youths may pass albumin for days together before an interval of 
freedom from it occurs. Sometimes they appear to be in robust health, sometimes they 
look a little pale, as though they had been overworking at an indoor occupation ; they 
may be nervous, but often they are not. A natural nocturnal emission is supposed to 
predispose to albuminuria next day ; so also is a diet which includes eggs, especially raw 
eggs. The point is that these individuals have to be differentiated from sufferers from 
Hright's disease. The method of diagnosis is as follows : a complete routine examination 
is carried out, and no obvious affection of the heart or other viscera is detected ; the blood- 
pressure is normal : the albumin having been discovered, the patient is directed to sui)ply 
a scries of samples, at intervals of a few days, and ])referably passed inmiediately after 
rising in the morning. If all samples contain albumin it will be very didicult to exrludc 
organic disease ; if some contain albumin in aliundancc, however, and others none at all, 
llie ])resu»iiptioii will be that it is • functional " : before l)eing finally satisfied, however, 
it is important that a careful microscopical examination of the centrifugalized dc)iosit 
from a specimen containing albumin should be made, no casts or other abnormal consti- 
tuents being found. The administration of calcium chloride or calcium lactate greatly .< 
diminishes the lendincy to this form of albuminuria. In an adolescent male who has no 
sym|)toms. albumimiria discovered accidentally, present after exertion or after exposure to 
cold, but absent alter rest in bed. and when |)resent not associated with renal lube- 
casts or with signs of arterial, cardiac, or other disease that should be delicled by physical 
examination, is almost certainly " phvsiological." needing no treat mcTit and not judical i\c 
of any lindcrlyiiii; disease. Ilrrlurl Fiiixh 

ALBUMOSURIA may be iliseussed under I wo main hca.liugs. naincly : (1) Onliiiiinj 
.llhiiiniisiiria. which is not uncommon but is of little clinical importance: and fJ) Hiiicc- 
■ loiits .llhiimnsiiriti. which is rare hut is clinically im|)ortant. 

Ordinary Albumosuria is seldom recognized because the albumose generally occurs 
along with albumin, and is not detected imlil this has been removed by acidulating with 
accli<- acid, boiling t iKiroii^lilv. and |j||( ring. Albumose mav be rceogiii/.cd in the lillrate 
by the facl tliMt with llillci--, nilrir aciil lest it uives a while cloud which disappears on 



16 ALBUMOSURIA 

warming, to reappear on cooling ; and its presence may be confirmed by the violet -red 
colour ft gives with the biuret test, which consists in adding excess of caustic soda to a 
drop of dUute copper sulpliate solution, adding this mixture in drops to the urine, from 
which all albumin has been removed, and warming. Another test for albumose is 
Hofmeister's, which consists in acidulating the urine with acetic acid and then adding 
phosphotungstic acid ; albumoses give a milky cloud with the latter. The deutero- 
albumose that gives these tests occurs in the urine under a great variety of circumstances : 
apparently the one essential factor is cell destruction within the body. It will suffice to 
mention some of the many diseases in which it has been found : — 

(a) ' Febrile ' Albumosuria : in severe infective fevers, such as tyijhoid. scarlet, 
small-pox, measles, acute rheumatism, lobar pneumonia. 

(fo) • Pyogenic ' Albutnosuriii : in empyema, phthisis with cavitation, bronchiectasis, 
appendicular subdiaphragmatic or hepatic abscess, suppurating gall-bladder, pyosalpinx, 
suppurative periostitis, arthritis or osteomyelitis, gangrene of the lung, gangrene of the 
leg, breaking-down cancer, acute peritonitis. 

(c) • Hepatogenous ' Albumosuria : in cancer of the liver, cirrhosis, catarrhal jaundice, 

phosphorus poisoning, acute yellow atrophy, infective cholangitis, suppurative jn lci)hlehitis. 

{(I) ' Alimentary' Albumosuria : in cases of gastric or duodenal ulcer, carcinoma of 

the colon or stomach, ulcerative colitis, tuberculous ulceration of the bowel, acute and 

chronic dysentery. 

(e) • Hcvmatogenous ' Albumosuria : in leuka-mia, scurvy, purpuric conditions, and 
with internal hcematomata, such as pelvic hsematocele. 

(/) ■ Albuminuric ' Albumosuria : many cases of acute nephritis, syphilitic, cardiac 
and other forms of albuminuria, are associated with albumosuria. There is some doubt, 
however, as to whether the reagents employed in the qualitative analysis do not themselves 
convert some of the albumin into albumose. 

(g) Albumosuria due to unclassified causes : such as pregnancy, especially if the fcetus 
has died, though sometimes even without this. 

The amount of albumose present in any of the above conditions is seldom large, and 
diagnostically it has little if any significance except when it occurs apart from albumin. 
Even then its main importance lies in the necessity of not mistaking it for albumin. This 
error would only arise with the nitric acid test, for albumose does not form a cloud on 
boiling with acetic acid. It is urged by some that albimiosuria in appendicitis points to 
abscess rather than to simple inflammation ; that in a pleuritic case it points to empyema 
rather than to serous effusion : that in a mcningitic case it points to the suppurative or 
epidemic cerebrosjjinal forms rather than the tuberculous ; and so on ; but it is very 
doubtful if the symptom can carry so much weight as this. In a given case the presence 
of ordinary albumosuria points to a graver prognosis upon the whole than if no albumose 
were present, but it is not particularly helpful in differential diagnosis. 

Bence-Jones Albumosuria, on the other hand, though rare, is clinically important. 
The nature of the jiroteid present is still undecided : it certainly is not ordinary albumose. 
Its most striking characteristic appears when the urine is warmed after aeidulation with 
acetic acid to prevent precipitation of phosphates : long before the urine boils a dense 
milky precipitate appears, suggesting at first sight either phosphates or coagulated 
albumin ; it attracts attention at once from the fact that on further warming it begins 
to clear up again, and after boiling it almost or completely goes. It will be reaUzed that 
the precipitat'e cannot be albumin or phosphates, for not only would neither of these clear 
up at boiling-point in this way, but also the aeidulation of the urine has been sufficient 
to prevent phosphates from coming down, whilst the temperature at which the dense 
sticky precipitate appears (about 60° C.) is far lower than that at which albumin coagulates. 
If any albumin is present at the same time the clearing at boiling-point will be but partial ; 
the albumin should then be removed by boiling and filtration, when nitric acid added to 
the filtrate will gi\'e a white ring which redissolves on warming, to reappear on cooling, 
like that of albumose. This Bence-Jones proteid, when present, generally occurs in much 
larger amounts than ordinary albumose ever does, so that it is seldom overlooked unless 
it is mistaken for albumin. It may amount to anything between 1 and 20 parts per 
thousand, or more. It may be present on some days and not on others. It indicates, 
almost with certainty, that there is some affection of the bone-marrow ; it might be due, 



AME\()RHH(EA 17 

for instance, to secondary deijosits of nialignant disease in bones, or to leukieniia : but 
in the great majority of cases it has occurred in connection witli multiple myelomata — 
Tvahler"s disease or myelopathic albumosuria of Bradshaw. Unless there is other evidence 
ro the contrary, abundance of Bcnce-Jones i)roteid in the urine indicates multiple tumours 
in%olving the bone-marrow, Herbert Freiieh 

ALKAPTONURIA. — (.Sec Urine, Abxormai. Coloratiox of. p. 74C.) 

ALLOCHEIRIA — Literally means ' other handness.' It sometimes happens that 
when a patient is touched upon, say, the back of his right foot, and is then asked where 
he has been touched, he says, " Upon the back of my left foot." This reference of sensa- 
tions to exactly corresponding parts of the limbs or body on the wrong side is known as 
allocheiria. ]-:xperiments have shown that complete allocheiria results from transverse 
hemisection of the spinal cord. It seems that sensory impulses travel much the more 
readily up their own side of the cord, but can also pass by the opposite side if necessary : 
when they arc compelled to do .so, the brain interprets them as coming from that side of 
the body which usually sends impulses up tliis particular side of the cord. AMien a patient 
exhibits allocheiria. therefore, it generally indicates that there is a lesion affecting one side 
of the spinal cord, or the upward extensions of the tracts which convey sensory impulses 
from the cord to the brain, more than the other. It is necessarily a rare symptom. It 
might result from a stab or a bullet wound damaging the cord unilaterally ; or from a 
gununa or neoplasm of the spinal meninges ; it may be functional ; rarely it may result 
from the cord becoming comjjressed more on one side than on the other by spinal caries, 
a new growth, callus, or a fracture-dislocation : and occasionally it may be noticed when 
there is a cord disease which, though usually bilateral, happens to have advanced more 
rapidly on one side than upon the other, as in exceptional cases of disseminated sclerosis, 
locomotor ataxy, or softening from syjjhilitic endarteritis and thrombosis. Except in 
functional eases, allocheiria will seldom be the only, or even the chief, feature in the case : 
paresis, pain, or some other symptom i)resenl will afford greater assistance in the diagnosis 
than will the allocheiria itself. Herbert FrencI,. 

ALOPECIA.— I See Hai.dm-.ss. p. 70.) 

AMAUROSIS.- (See N'isio.n. Uia-ixrs ok. p. ?.-,«.) 

AlVlBLYOPIA.^(Sec Vlsion. Dki-hcts oi-. p. T.>!t.) 

AMENORRHOHA.- 'I'lie lime al which menstruation lirsl appears is very variable 
wilhiii (crhiiii Imiits, being itilluciieed largely by climatic and racial |)eculiarilies : in this 
■ounlry alioul roiirleeu may be taken as the average. When the meiislrual Mow has not 
X'ciime cslablislicd it is usual to speak of primary amenorrluea. whilst cessation of the 
How alter II has once been regularly established is known as secondary amenorrluva. From 
the lahlc of the causes of amenorrha-a below, it will be seen that .some of them must 
f necessity give rise to primary anienorrlKea. whilst others more coirunonly produce the 
icoiulary variety. In investigating a ease, therefore, it is imijortant to ascertain first 
whelher the condition is primary or secondary, and next whether it is real or only apparent. 
The latter cotidilion. known as cryptometiorrlKra. implies that the menstrual How takes 
place but is imable to escape exiernallv because there is some closure of a pari ot Ihe genital 
an.il. The congenital I'oriTi of ( iyploMienorrh<ra is the only vari(l\ nicl willi al .ill 
ominonly, accpiircd closmc i<\ a pari of Ihe genital canal being cxeciilingly rare. Slenosis 
il IIk' \agina is not iinconurron as a result of injui-y and infection, but a srrrall sinirs is 
iisrially lell which srrlliees lor tire escape of the menstrual llriid. We are led lo suspect 
rxploineirorrlroa when the patient volunteers the statement that she has pelvic pain, 
headache, and jio.ssibly vomiting, of monthly occurrence, in fact the usual rnenslrual 
molimina. unaccompanied by any visible How. .\ physical cxaminalion shorrld be made 
a( oiici' in such a ease, iirehrdiiig abdominal palpation, inspect ion oi I lie \ril\ii. arrd a i-eeto- 
ilxlominal bimanual exainirralirrn. The coirrnron form is thai in uliicli Ihe lower- end 
>f Ihe vagina is irnperfor-ali'. Ihe liynicn iisrrally bcirrg visible on llie outer side of Ihe 
■Cdudiirg rrrernhrane. The eoir.|,lrt,- , xainniiilion irr sncli ;i case uill i-e\eal a llnel iral ini; 



18 



AMENORRHa^]A 



.swcllinji- reaching from the \iilva to tlio ])clvic brim, above which the uterus can oftii 
be palpated and moved about. It is further of considerable importance to make oni 
wliether the uterus and Fallopian tubes are distended with menstrual products alonu- witi 
llie distended vagina, for in the presence of ha-matosalpinges the treatment is considerablx 
modified. Abdominal section is required in such a case to avoid rupture of the tubes wlici 
tlie vajiina collapses after incision of the occluding membrane. Distention of the vagin; 
(jr hicmatocolpos is complete in this case, but may be partial where the lower part of tli( 
vagina is absent, and then is likely to be accompanied by distention of the uterus 
(ha-matometra) and ha-matosalpinx. Complete absence of the vagina can only be inferrei 
from ]3hysical examination, when the distended organ appears to be only the uterus. 
Although a secondary phenomenon, acquired cryptomenorrhoea produces the saim 
symptoms and requires the same kind of investigation as the congenital ca.ses. It niu^ 
not be forgotten that ae<|uired closure of tlie vagina following the vaginitis of specific fe\ ( i 
may t)ccur in infancy, and will then, of course, produce ])rimary amenorrhoea. 



CAUSES OF APPARENT AMENOHRHCEA. 



Cniigeiiilal : 

Iiiipeiibrate vagiiui 
Iniporforatc hymen 
AljseiK'c of the vagiiui 
Acijuireil : 

Closure of the vagina : 
Due to specific fevers 
Due to injury 



I'lii/sidlogicdl : 
IJeforc puberty 
After the menopause 
During ])reanancy 
During lactaticm 

I'alliohgiail : 

(Jenerative System : 

Ah.sence of essential organs 
Infantile uterus 
Small adult t\pe of uterus 
Deficient ovarian activity 
Destruction of both 
ovaries : 
By double ovarian 

growths 
I?y )ielvi<' iMll;iinniatiiin 
Supcriiuohitiiui oi' the 

uterus 
Note. — Real atnenorrlicpa 



Ini])erf'oratc ecr\ix 

Double uterus with retention 

Hivmatocolpos 



Ilaniatometra 
Iheinatosalpinx 



Closure of the cervix : 
Due to injury 
Following operations 



CAUSES OF REAL AMENOI?RHCE 
Circulatory System : 
Chlorosis 
Anfemia 
Leueocvtha'uiia 
II(i(lgkiM"s disease 
Wastiiii; iliseases : 

Ahili^iiant growths 

Tubercle 

Prolonged siippiu'ation 

Diabetes 
Late stages of nephritis 
Late stage of some forms of 

heart disease 
Late stage of cirrhosis of 

the liver 
Nervous system : 
Tnihceilifv 
L' Cretiiiisni 

\'ari<nis fdi'ius of insanity 

nay be (1) Primary witli delayed onset ; 
(3) Secondary. 



Cold just before or durini 

menstruation 
Suggestion — fear of ijreg 

nancy 
Anorexia nervosa 
Altered internal secretions : 
Myxoedema 
Exophthalmic goitre 
Addison's disease 
Acromegaly 
Obesity 

Change of habits 
Toxic : 

After specific fevers 
Chronic poisoning by lead 

merctuy, morijhia, alcoho 



(2) I*riinary and permanent ; 



In considering tlie diagnosis of the causes of real amenorrhoea. the primary ani 
secondary forms afford us an important clue to the possible causation. Suppose, fo 
instance, that menstruation has once been established regularly, it is clear that there canno 
be any serious congenital anomaly of the generative system ; the uterus and ovaries mus 
at least be present and functional. We then must make a systematic examination of th 
generative, circulatory, nervous, and ductless gland systems, in order to learn by a proces 
of exclusion which group of causes we ha\'e to deal with. If. however, the amcnorrhoei 
is primary and real, that is. the patient has no molimina, our examination nuist first b 
directed towards finding out whether the essential organs, namely, uterus and ovarief 
are present, and are normal in size and shape as far as a bimanual examination can ascertain 
ir necessary, an anaesthetic may be given for this purpose, for it is often a matter of c;)n 
siderable difficulty to decide the question. If the fact of absence of the essential organ 
can be established, we are clearly justified in considering the amenorrhoea to be permanent 
and the patient or her friends should be told of this. 



AMNESIA 19 

Ajjart from congenital anomalies, it is remarkable how few lesions of the generative 
(irjiaiis there arc which produce amenorrhoea ; only those diseases which destroy both 
ovaries completely or render the uterus functionless can cause amenorrhoea, and under 
this heading we find only double ovarian growths, the late stages of pelvic inflammation 
(sali)ingo-o6phoritis), and superinvolution of the uterus. A tumour destroying one ovary 
as a rule has no effect on menstruation at all. provided the other is present and I'lmctionally 
perfect. It is possible for one ovary only to be functional : for instance, that on the same 
side as the undeveloped half of a unicornuate uterus may be quite atrophic and functionless. 
The presence of two tumours in the abdomen symmetrically arranged with regard to the 
uterus will sometimes permit of the diagnosis of double ovarian destruction, but quite 
CDiiimonly one tumour is much larger than the other, and the double nature of the lesion 
cannot be established initil the abdomen is opened. Su])erinvolu_tion of the uterus is not 
dillienlt to recognize when we remember that it always follows pregnancy, and the small 
size of the uterus can be made out readily by bimanual examination and the passage of 
the uterine sound. The organ sometimes measures only IJ inches by the sound. It must 
not be forgotten that even in these cases the primary lesion may be an ovarian atrophy, 
but very little is known on this point. The term "" deficient ovarian activity "' is a time- 
honoured one. and must be taken to mean the absence of the internal secretion of the 
ovary. It is obvious that this condition cannot be diagnosed by any physical examination, 
and its presence can only be inferred when absolutely no other lesion of any system can 
be found to aecoimt for amenorrhea, either primary or secondary. 

It is impossible in the space at our disposal to draw up any detailed method by which 
the various diseases under the circulatory, nervous, etc.. systems, can be diagnosed ; these 
are discussed under the headings of other symptoms that they produce. It is, however, 
not out of place to note here that amenorrhoea caused by general diseases, unconnected 
with the generative .system, depends upon : (1) Alterations in the blood itself ; (2) Alter- 
ations in blood-pressure : (.3) Altered relation of the nerve impulses which form part of 
the stimulus for menstruation : (4) Altered relations between the internal secretions of 
llie ovary and the thyroid glands on the one hand, opposed to the suprarenal and pituitary 
irlands on the other. Finally, with regard to ])rcgnaney. which is the conuiionest of all 
causes of secondary amenorrluea, it may be fornuilated as an axiom that an otherwise 
healthy woman who has had perfectly regular menstruation is probably pregnant if she 
has a jjcriod of absolute amenorrhoea. Nevertheless, the presence of pregnancy must 
never be assumed without a most careful consideration of the history, combined with a 
complete physical examination. The diagnosis of pregnancy nuist always l)c made uixm 
a complex of syrTiptoms rather than upon any one : the combination of amenorrhoa, 
secretion to be s<)tieezed from the breasts, morning sickness, vaginal discoloration, and an 
abdominal tumour, can only mean jiregnaney in the vast majority of eases. The addition 
of I'o'tal ino\cnicn(s and the lietai heart-sounds iiiaki- the diagnosis absolute. 

T. (1. Stevciit. 

AMNESIA (Loss of Memory). Memory is one of the higlicv funelions of the brain, 
and presents wide Narialions in ifs degree of de\(lopiiient in dilferent indixiduais. 'flic 
physiological range being so extc'MsJNe. it is almost impossible to say whether an apparently 
poor memory is pathological or not. when llic condition is of long standing and stationary. 
.Slight degrees of impairment of inciiiory arc of interest to the psychologist, but to the 
majority of tneclieal nun the loss must be considerable or of peculiar character before it 
is of diagnostic iniportanee. In some forms of excitement there may be exaltation of 
memory (hypernuiesia ) ; cxciits are recalled and magnified in importance, wliich in normal 
states would never have icaclicd the surliK'C of conscious memory. In all i'ornis of 
dementia, on the oilier hand, memory becomes impoverished (hy])omnesia). and may 
eventually fail altogether (amnesia). Ucferenee can l)e nia<le to only a lew states in wliich 
the condition of memory may be of service in diagnosis. 

Dnnnilin. In all forms of dementia senile, general paralytic, toxic, etc. memory 
is impaired, and it is the rule to find that recent c\cnts are lost before those belonging to 
distant y<ars. I'',\<n when memory is obliteratcil almost completely', a few isolateil events 

in the past may lie recalled distinctly will I llieir surroundings, and inav lake a 

prominent place in the ])atient"s personalilv. These traits charaeteri/e seuilil\. bid arc 
also t<i !)(■ roiiiiil, when IddUcd l(ir. in oilier dinuiilcd slates. 



•20 AMXESIA 

Epilepsy. — Amnesia is an important feature of the epileptic seizure ; in the majority 
of epileptics no memory of the convulsion is preserved, although events immediately 
preceding it may be retained clearly, as well as those which follow the return of consciousness : 
in other cases the amnesia may cover a period preceding the attack (retrograde amnesia),' 
while in others, actions are performed after the attacks, in an apparently conscious state, 
which the patient is quite unable to recall later on. To this phenomenon may be applied 
the term antegrade amnesia in association with post-epileptic automatism. Epileptic 
amnesia is often important in connection with medico-legal questions and criminology. ' 
In addition to temporary lapses of memory, the majority of epileptics suffer from the 
progressive hypomnesia common to all forms of dementia. It is one of tlie first signs of 
their intellectual deterioration, and not the result of the administration of bromides to 
which it is generally attributed. 

Trnnma. — Severe falls or blows on the liead often cause complete amnesia ; the latter 
may cover not only a period of unconsciousness, but also a period preceding or following it, 
or both. As in cases of epilepsy, the amnesia may be retrograde, anterograde, or antero- 
retrograde. 

Korsakozv's Syndrome. — This condition, generally the result of alcoholism, is character- 
ized by hypomnesia, disorientation, and pseudo-reminiscences. The patient loses memory 
for recent events, has no appreciation of time or place, talks freely and often plausibly 
about events which have never occurred, and yet may retain a very natural attitude of 
mind towards his surroimdings. So natural may be his manner of talking and his behaviour, 
that the above-mentioned mental deficiencies nray escape notice unless the medical man 
a[)i)lies himself to their discovery. 

Toxcemia. — In many infective diseases, such as enteric fever, the return of health may 
reveal a state of amnesia covering a considerable part of the patient's illness, and this 
blank, the result of intoxication of the higher cerebral centres, may be permanent. 

Hysteria. — Anmesia is probably quite complete in connection with some forms of 
hysterical ' fits.' The patient in the interval between attacks has no recollection of the 
latter, although they are not associated with loss of consciousness. This fact underlies 
the theory which assumes a double consciousness ; the person in one state of conscious- 
ness has m memory for events which oeciu' in the other. E. Far(jnli(ir Buzzard. 

ANEMIA is a general and inexact term which may include one or more, or even all, 
of several iliflerent changes in the blood, but of which the main criterion clinically is 
diminution in the amount of haemoglobin contained in a given volume, usually but not 
invariably associated with a decrease in the number of red cells per c.mm. of blood. Changes 
in the leucocytes are not essentially related to anaemia, though their behaviour affords 
means of diagnosing some forms of aniemia from others. Various terms have been used 
to denote different ways in which the blood may depart from the normal, and these may 
be defined shortly, though they are seldom imjaortant in practice. 

Olisocytlia'itiid or hypoeythcemia both signify a diminution of the number of red cells 
below the normal 5.(H)0,()00 per c.mm. of blood in a man, 4,500,000 in a woman. Oligcemia 
means a diminished total amount of blood in the body ; hydrceniia, an increased percentage 
of water in the blood ; polyplasmia, an increase in the volume of the plasma of the blood 
such as occurs in chlorosis ; oligochromcemia, a diminution in the amount of haemoglobin 
per c.nun. of blood. 

For purposes of comparison of one case with another, one speaks of the red cells and 
of the haemoglobin as being normally 100 per cent in health. An anaemia may be such 
that the haemoglobin is greatly diminished without so great a diminution in the red 
ct)rpuscles : it is also possible for the haemoglobin and the red cells each to be diminished 
in e<|ual proportions ; and thirdly, it is possible for both the haemoglobin and the red 
corpuscles to be diminished, but for the hffimoglobin to be relatively less so than are the 
red cells. The red corpuscles contain relatively less haemoglobin than they ought to in the 
first variety of anaemia, which is probably the commonest of all ; in the second group, 
although there is ana^nia, each red corpuscle contains its full quantity of hirmoglobin : 
whilst in the third group, although there is anaemia, each corpuscle contains more haemo- 
globin than it normally should. .As a means of expressing these facts shortly, one speaks 
of the colour index : this is the ratio of the haemoglobin tf) the red corpuscles. If the red 



AX.EMIA 



21 




corpuscles and uemoglobin are each 100 per cent of normal, the colour index is kip „, 1 
If the ha.moglob,n were diminished to 40 per cent of normal, whilst the red cells l^^ onh- 
hmnnshed to 80 per cent of normal, the colot.r index would be 4§. or 0-5-the mZhc 
Hipe. ,n w uch he mdex ,s less than 1. If the ha-moglobin and the red cells we,rbot^^ 

-"or t irt. r" ""I , "°'""'- :'"^ "°""* ''" '"^'"■"'" -'*" - "-„,al colour ndexo 
„ or 1. If the lurmoglobm were dimimshed to 30 per cent of normal, whilst the red 
cells were dnnm.shed to 20 per cent of normal, the colour index would be au or i-5- 
that IS to say, greater than 1, a condition which is spoken of as the pernidous type of 
colour mdex, because it is seen best in pernicious ana?mia. ^^ 

Pallor may or may not indicate 
anapmia. Many per.sons look almost 
white, and yet their blood is not in 
an abnormal condition. Pallor is nor- 
mal in night-workers and in those who 
work underground. Even in some 
daylight workers the distribution of 
the cutaneous capillaries seems to be 
such that the superficial skin has little, 
if any, of the normal colour of blood, 
and yet the individuals arc not ana?mic 
in the sense of having any diminution 
of the ha'moglobin or the red cells. 
The error of mistaking mere pallor for 
iina-inia is avoided by means of a eve,, mm 
l)lood-count. which in all cases should 

inclu.le estimation of the percentage of haemoglobin, and of the total number of red cells 
.er c.mm • and in most cases determination of the number of leucocytes per c.mm a 

i:;::;:d^::;^'fihr:,r"' ""' ^" ^^^"""^*'°" °^ ^"^ ^'-^-^-^ «^ ^'- red'^orpusdesin 

Corpuscles are best counted hv nu-Miis of tlie Tlionia-Xciss or Tl.nm., I ..;* i 

Having proved that the patient is suffering from real ana>mia. that is to say from 

innution in the percentage of ha-moglobin. and probably from a diminution in the red 

Is dso. the next step in the diagnosis is to ,l..ter„,ine what is its nature. Attempts Ire 

nct'-cs ma,le to ht all cases of ana-mia into one or other of two main grou s itnJd 

m,,,,,-!, and .«ro,,r/«ny respectively; but this is noi reallv very helphif clinical In 

n||ny e..es the nature of the ana-mia is obvious at once-^t may be ™ a v o po^^ 

.ar uu han,or,l,age or other blood loss, or the later stages of phthisis, svphil s ca icer 

IK arKd cachexia, and so„n. Sometimes, however, even though ana.mii is n. Iv h^ 

. a use which ,„ some patients is obvious, it is not obvious in (he pali..,,, with whom one 

.nc ""„''""'"«• ""•' '""> "-• ^'-«""-« '- to be arrived a, bv a pro<.ess of ex.^l .13 

Lis r^ '"";'"' '".™'"""'-- l-'-|.s. the diineulties that arise sometimes 

agnosinn l,,|wee„ lungaling en.loearditis. gastric eareinoina. and pernicious anxmi- 

he ween a„:..„.,a dii.- to blood-loss and bloo.l-,..ss due to anemia.' In arii^a 1; 

' . . . ) . un,n.,s n , , „. n„Hrnnn..„r or nrgaNvc WW pirl.n: is probablv more 

i n < 7,; Lr ;'''";:'■'■ '■'":'^"''-"""- ''-'-■ ""•>• — -- m which tn.: biood 

;::.;.-;i.tiu";:;:';,;;;:;;;;;;^:;r;;;;;--^ 

"r;,;:::;:"'""-" "'" ' ' "" '■'' -""■ — - — -1;,';::::::;;:: 

Blood Changes common to all .Severe Ana-mias. I,, mmv s.x.n a„.,M,ia Ih.n ar.. 



.22 AN.EMIA 

certain blood changes wliich are almost always to be found, which are not characteristic 
of any one variety of anaemia, but which, seeing that pernicious anaemia in its later stages 
is |)robably the profoundest of all the ana?mias, are perhaps better seen in it than in any 
other disease. These are : — 

(a). A very great diminution in the iiiiiiibcr of red corpuscles, down even to so low a 
figure as 600,000 per c.mm. 

(6). Great variation in the slnqyes of the red cells — poikilocytosis ; poikilocytes 
(Plate II. Fig. E) always retain a smooth, curved outline, but instead of being flat circular 
discs, like normal corpuscles, they may be oval or pear- or hour-glass-shaped, and so on. 
It is important not to mistake crenated corpuscles [Plate II. Fig. D), or red cells that have 
become polygonal by reason of mutual moulding when fixed in too close apposition with 
one another (Plate II, Fig. C). for poikilocytes. 

((•). Alterations in the sizes of the corpuscles. In normal blood the red cells are almost 
all of the same diameter, about 7/i : in any severe an;emia they may vary considerably in 
size, many being much smaller than iwrmnl—niicioeyfes (Plate II. Fig. li) : some larger 
than normal — macrocytes or megalocytes (Plate II, Fig. B). 

(d). The presence of nucleated red corpuscles. Normally none are present in the blood 
even in infancy ; in any severe anaemia they may appear in varying numbers, and according 
to their sizes they are termed microblasls. normoblasts, megaloblasts. or gigaritoblasts (Plate II, 
Fja, P) the latter containing more than one nucleus, the others only one. It has some- 
times been stated that the greater the number of nucleated corpuscles the less favourable 
tlie prognosis, but this is not necessarily the case, except in so far that it is unusual for 
nucleated forms to appear until a severe stage of the anaemia is reached. 

None of the above changes, one must repeat, are diagnostic of any particular variety 
of severe ana-mia, though they are perhaps most marked in the later stages of pernicious 
aniemia. 

Normal Varieties of White Corpuscles. — It often happens that variations in the 
relative proportions of the different leucocytes in the blood afford means of differential 
diagnosis. Before changes from the normal can be understood, it is necessary to say a 
word or two about the normal varieties of white cells : these number anything from 5.000 
to 10,000 ])er c.mm., the total changing considerably at different times of the day. \V\\en 
lilms are made it is found that four easily distinguishable varieties are to be seen. These 
have received different names at the hands of different observers, but they are so distinct 
tliat names hardly matter, and they might be termed quite well types A, B, C, and D 
respectively. If. however, one has to choose between the different names that have been 
g.\en to them, the following may jjerhaps be selected as the most frequently employed :— 
(\) Small lymphocytes : (2) Large- lymphocytes ; (3) Polymorphonuclear cells ; (4) Coarsely 
granular ciisinophilc cdr/iiiscles. 

1. The stiKill IjinipliiHyles (Plate II, Fig. H) stain blue with Jenner's stain, both as to 
nucleus and proto|jlasm. The nucleus is round, and the i)rotoplasm is relatively small in 
amoimt and free from granides. 

2. The large lymphocytes, or Injaline corpuscles (Plate II. Fig. J), stain blue, both as 
to nucleus and protoplasm. The nucleus is more or less kidney-shaped, and the proto-, 
plasm relatively large in amount and free from granules. 

3. The polymorphonuclear cells (Plate II, Fig. K) stain blue as to the multilobed, 
nucleus, red as to the relatively abundant protoplasm, which imder the high power isl 
seen to be speckled with very fine red granules. 

4. The coarsely granular eosinophile corpuscles (Plate II. Fig. L) stain blue as to thi 
multilobed nuclei, red as to the protoplasm, the amount of which is approximately tlK 
same as in the polymorphonuclear cells, but differs from the latter in that it is studdet 
with very striking large eosinophile granules. 

The Only dilliculty that arises in making a differential leucocyte count in normal bloof 
is that whereas tlie small lymphocytes usually become fixed in such a way as to covei 
relatively small areas, so that the cells seem to consist mainly of nucleus, at other time: 
tliey spread out flatter over larger areas, and then the rounded nucleus seems to bi 
surrounded by much protoplasm (Plate II. Fig. I). A small lymphocyte flattened out ii 
this way is apt to be called either a large lymphocyte by those who do not insist upon \\v 
reniform micleus of the latter, or a transitional lymphocyte by others. There is no deductioi 



PLATE .II 



RED XND WHITE BLOOD CORPUSCLES 

As seen umler the ',th inrh .ijl-hiiiiifrsion lens. 



o 






♦ofJ^ 




^i:K;.^ 




^^Hp »^' 



IP 




CoiiyriijhI. 




"" V^ 







7. /^ Ford, lid. 



A. Normal red corpuwU's; B. Mc?,'alocytes and microcytfs ; C. Ni)rniJil red corpuscles made aiiiiulnr by imperfect 
ILvntlon ; D C'reimted red <(H'pUik.*Ie»; E, I'oikilocylori ; F. Xucleuled rod corpuscles; {!) Xormobkisis, (2) Megaloblnsts; 
(.1) <;ii;antobla«l.s; G. I'liiictuto biisophillu niid polychromnsia; H. Small lymphocyte; I. Imleterminatc lymphocyte; 
J. I.Hree hyaline lymjilioc-yic; K, I'olymorplioniiclcar corpuscle; L, Coarsely granular eoaiiiophile corpuscle; M, 
Myelocyte; N. Kosinophtk-'inyelocytc ; *0. Hsiwdphilc corpuwle, 

SliKX 01' iu,\r;N(»s(s— 7V. /air /t. '2'J 



AN.^iMJA 23 

of particular clinical value to be obtained by distinguishing these cells from small lympho- 
cytes : it is better that they should be grouped with the small lymphocytes for clinical 
purposes at any rate, only undoubted large hyaline cells with reniform nuclei being 
included in the group of large lymphocytes or hyaline corpuscles. 

The relative proportions of these cells differ according as the individual is a child 
a grown-up person : for an adult one may say that, roughly speaking, out of 
100 leucocytes 

Alioiit 2.") will III- siiiiill lymphocytes 

S will be lai>;e hyaline lymphocytes 

65 will be polymorphonuclear cells, and 

2 will be coarsely granular cosinophile corpuscles 

100 

In children the tendency is for the small lymphocytes to be relatively more numerous 
in health, and still more so in any illness — up to 40 per cent or even more — whilst the poly- 
morphonuclear cells are correspondingly diminished. 

Some observers prefer to represent the different varieties of white corpuscles not as 
percentages but as total numbers per c.mm. of blood. 

Abnormal Varieties of Wliite Corpuscles. — \Vhereas the above are the only kinds 
of white cells in healthy blood, in certain diseases the following abnormal forms are met 
with :— 

Myelocytes. — These are large cor]niscles (Plate II, Fig. M), comparable in size to the 
polymorphonuclear cells, but differing from the latter in having either a perfectly round, 
an oval, or possibly a slightly kidney-shaped nucleus, rather than a multilobed one. There 
are all gradations of them, and at the two extremes it is difficult to differentiate some from 
large lymphocytes and others from polymor])honiiclear cells. They arc to be distinguished 
from the latter by the roundness of the nucleus, and from large lymphocytes bv the 
granularity of the protoplasm. The granules in fpiestion are sometimes stained brightly 
with eosin — cosinophile myehrytcs (Plate II, Fig. iV), distinguishable at once from the 
-)rdinary eosinophile corpuscles by their nuclei being nearly spherical : more often, how- 
-'ver. the granules stain blue, or some colour between blue and red — ordinary or neiitrophile 
'Hyeloeytes. No uselul clinical information can, so far as is at present known, be oi)taincd 
)y laying stress upon these differences in the staining reactions of different mycloc-ytes, 
io that they are usually coimted together simply as myelocytes. There is only one condition 
n which they are very numerous, and that is spleno-medullary leukicmia : but the\- may 
)CCur in small numbers in various other affections also, particul.nly in lymphaih iioiiia, 
Hodgkin's disease, i)ernicious ana'inia, and aplastic ana>mia. 

Iiasoj)liile Coijiiisctcs (Plote II. Fig. ()). — These are nuich smaller Ihan myelocytes, 
:heir size being comparable to thai of small lymphocytes: they differ from the latter in 
hat the prolopliism. instead of being homogeneous, contains from 2 or .'J to jicrhaps 20 or 
norc very large gramdes which stain deep blue with Jenncr's stain. They are unniistakc- 
ible. No deliiiite clinical deductions can be drawn from their presence beyond the fact that, 
r there are more than 1 or 2 per 1,000, the blood is abnormal. They may be present in 
nany different varieties of anatnia, but they are not characteristic of any: they seldom 
iniount to more than 2 or :i per eciil, and oflcn to no more lliaii ()•.". per ecnl, even 
n disease. 

Plinctale ISiisDjihiliii. 'I'Ikic mic ccrlairi coiKlil ions, pailieiilarl,v pririieioiis aiiainia in 
ts later stages, leukaniia, and lead poisoning, in which the red cells, instead of staining 
liuforrnly pink with the eosin of .lenner's stain, ])resent large munhers of small blue specks 
ir granules in Iheir protopl.ism (Plate II. Fig. (1). a condition known as pinietate haso/iliilia. 
[n a case of doulil. when pcriiicioiis anainia has been cxelude<l by there being a low colour 
ndex, and wlicn leukaniia is conl raindiciilcd by llic fact llial there is a normal leucocyte 
:ount, the pnsciice (it extensive piMK'lale basophilia is said somclimes to alfonl eiin- 
irinati\c evi.lenec (if pjnnibisrri. 

We iiiiiN now pass on lo eiiiisidcr the e iiKinei' \arielies of an:eMiia. (lealilii; liisl with 

mjeniias wilh p(isili\,. |,|oo>l pictures. 



24 AN.EMIA 

(.1).— AN/EMIAS WITH POSITIVE BLOOD PICTURES. 

Pernicious Anaemia is a distase (jf insidious onset in adults, the main syni|)toins heino; 
progressive loss of muscle-power and increasing pallor, with loss of weight, but with 
relatively less loss of body volmnc. Various other symptoms may be associated with 
these, or no others may be present. The diagnosis is seldom made until a relatively late 
stage of the malady has been reached, by which time there is a great diminution in the 
hipmoglobin, down ])erhaps to 30 per cent of normal or less, and a still greater diminution 
of the red cells, down perhaps to 25 per cent, 20 per cent, or even 10 per cent of normal ; 
consequently the colour index is high, and this is the pathognomonic sign of the disease. 
Tiiere is no leucocytosis, but rather leucopenia (p. 3S1) : the differential leucocyte count 
shows a relative increase in the small lymphocytes, a corresponding diminution in the poly- 
niorphonuelear cells, normal numbers of eosinophilc corpuscles and large lymphocytes, 
occasional bas()i)liili' corpuscles, and one or two myelocytes. Blood films also show all the 
changes described above (p. 22) as conmion to any severe anaemia, but with particularlj- 
large relative mniibers of megalocytes. When these blood changes are all present there 
can be no doubt about the diagnosis, and we need not enter here into all the other symptoms 
that may be presented by the patient. It is important to remember, however, that there 
is one group of the cases in which ner\e symi)toms predominate before the anaemia is 
pionounced. The diagnosis of ])crnicious antemia cannot be made without a blood-count, 
anil it can be made absolutely with one : one word of warning is required, and that is that 
the colour index is not continuously high in every ease of jjernicious anaemia, so that perhaps 
several blood-counts may be required at intervals. It should also be noted that the power 
of temporary recuperation is considerable, and wlien the patient's condition improves the 
Ijlood may return partly or wholly to normal ; during such remission the colour index, 
instead of remaining greater than 1. becomes 1 or less than 1. 

There are certain cases of very severe ana;mia which some would include under the 
heading of pernicious anaemia, although the colour index is persistently less than 1. It is 
more useful, however, from a clinical point of view to leave these cases unlabelled, or at 
any rate not to call them pernicious anaemia, which has so characteristic a tjlood picture. 
One variety has recently become separated from the rest under the title of aplastic (nurmia. 
the cliief characters of which are a profound, [jrogressive, and ultimately fatal anicmia 
for which no cause can be foinid. which seems in many respects to simulate pernicious 
an;emia, but which is persistently associated with a low instead of a high colour index. 
It is, moreover, imaccompanied by a positive Prussian blue reaction in the liver — Perrs 
test with jjotassiimi ferrocyanide and hydrochloric acid — post mortem : this, when positive, 
is strongly confirmatory of pernicious anaemia, for very few other conditions give it, and 
they are rare sprue, for example, is one such, and bronzed diabetes another. 

Spleno-meduUary Leukaemia. — In the earlier stages of this disease there is no antemia 
at all, though later diminution both in the ha-moglobin and in the red cells may be profound. 
The essential ])oint in the diagnosis is the occurrence of a very great increase of the total 
number of leucocytes, not at all uncommonly up to such a figure as 200,000, and sometimes 
up to 600.000 or even 1.000,000 per c.mm. There is only one other condition which can 
l)roduce so extreme an increase in the total number of leucocytes, and that is It/mphalic 
Icidiccmia. The two are immediately distinguishable from one another by the differential 
leucocyte count, the characteristic point about which, in spleno-medullary leukaemia, is 
the large number of myelocytes present. These may amount to £0, to even 50 per cent, 
or more, of all the leucocytes present, with the consequence that there is a relative but 
not an absolute diminution in the other varieties of white cells. Occasional basophile cells 
are seen : but whate^•er may be the proportion of these or other leucocytes, the main 
jioint in the diagnosis is the large relative number of myelocytes in association with an 
enormous increase in the total leucocyte count. When an<emia ultimately ensues it is of 
the chlorotic type : that is to say, tlie ha?moglobin falls before, and to a greater extent 
than, the red cells. The disease generally lasts from one to three years before ending fatally, 
and in the later stages all the blood-changes cliaract eristic of severe anaemia may be found. 
Clinically, the other main feature of the complaint is the enormous enlargement of the spleen, 
which here reaches dimensions bigger than in any other disease, the viseus often extending j 
right across the middle line to the right iliac fossa or down into the pelvis. It is note- 



■a 



I 



Tart of ii blooU lilm from 



of sovoro iiornicious unn-mui, sliowiiiK poikilocyle 
ludeatc'ij reii cells, utiij puiiftiite busophiliu. 



icytcs, mogiilOL'ytca, 



INni;\ (II- IIIAIINDSIS -Tn ji,,;- i>. H 



AN.EMIA 



25 



wortliy tliat in jiatients treated with the .i-rays the spleen very often becomes greatly 
reduced in size, and the blood picture may return nearly to normal, though it seldom if 
ever happens, even when the number of leucocytes ]3er e.mni. has reached the normal, 
that there is an absence of myelocytes in the differential leucocyte count. Notwithstanding 
this apparent improvement in the blood and in the spleen, the length of time the patient 
survives does not seem to be increased. The splenic enlargement is not associated with 
enlargement of the lymphatic glands. 

Lymphatic Leukaemia. — There is no age at which any form of leuktemia may not 
occur : but uijon the whole the spIeno-meduUary form affects adults rather than children, 
whereas the lymphatic affects children 
rather than adults. Its course is usually 
rapid and invariably fatal, death resulting, 
as a rule, within three or four months 
from the first definite sym])tonis. Ana?mia 
is much more rajiid in its development in 
the lymphatic than in the spleno-medull- 
ary form. The first symptoms may be 
either anaemia, or lymphatic glandular 
enlargement in the neck, axilhr, and 
groins, or the occurrence of purpura, epis- 
taxis or other forms of luemorrhage, or in 
certain cases a complete change in the 
ehihrs temperament in the direction par- 
ticularly of excessive irritability of temper, 
with loss of appetite and obvious and pro- 
gressive illness. There are cases in which 
no glands are enlarged, the diagnosis not 
being at all obvious without a blood-count. 
More often there is general enlargement ol 
he lymphatic glands, visceral and peri- 
)heral, sometimes a.ssociated with similar 
ucreasc in the size of other glands, par- 
icularly the salivary and lachrymal — 
'III ulic/.'s syndrome — and the spleen is 
I' il\ always palpable and sometimes 

n-'. though seldom so big as it is in spleiio-incdulJary Icuka-mia. Serous iiillammations 
" Miinnon. and there is apt to be pyrexia, as in other severe aiuemias. especially h) 
|||' no-inedullary leuk;emia {Fia. 4). Ilodgkin's disease (Fig. 247. p, ,570), and pernicious 
iiriiiiM iFi'S- "JKi, J). .">(><)). The diagnosis is afforded at once bv the blood-count in the 




FiV- 3.— A 
i laclirvma 
iipliutic leuka- 



of chronitT enlargement of the saliv.iry 
case of 
tKindlii lent hii llr. I'nchTid: Tiuili.r.) 



i,i'>nl\- of cas 



There 



a \iirving degree of 



in llic leucocytes, sometimes 




■0 L-liiirt (niortunt' anil evnninj,') in a t 
who improved very inurlicclly under 



. hdlar.- lonka-niia 
it wliile in liosiiital. 



•aching no higher than 2<),()(H) or .•iO.OOO, more ollen SO.dOO lo KHl.oiMt. and soiucliiiK s. 
Ut more rarely, lo rnueli higher figures, siicli as -JOO.OOO. (idO.OdO. ,S(M(.(!IH> or iven 
500,0(1(1 per e.iiiTii. Whalever the lolal leucocytes coiml. linwev.r. Ilie striking fealme 
the I ii.iriiioiis rclalixc increase in the small lyinphocylcs in tin- ililierenl iai leucocyte 
Hint. Out ol every hundred leucocytes it is not uifeommou to (itid thai <((>. or even 



AN.EMIA 



95 or 98 are lymphocytes : so that there is an enormous relative and sometimes absohiU 
reduction in the other white corpuscles. Amongst them will be found an occasional 
mvelocvtc and one or two basophile corpuscles. The red cells and the lia-moglobin 
become diminished progressively, and the former may exhibit all the other changes 
described above (p. -22) as characteristic of any very severe anemia. Whereas m most 
cases the colour index becomes less than 1 as the disease progresses, in a few mstances, 
especially some time before the end, the colour index has been found to be greater than 1, 
as it is in pernicious ana-mia. There is no likelihood of mistaking one condition lor the 
other on account of the changes in the white cells. 

Some authorities describe two t\Tes of lymphatic leuksemia according as the lympho- 
cytes seen in the films are of relatively large or small size : as has been explained above, 
however there is always difficulty in deciding whether differences in apparent size of the 
lymphoc'ytes constitute differences in kiiul. and there is no very great climeal purpose 
served in drawing the distinction here, unless perhaps that upon the whole the larger the 
lymphocytes present the greater the number of months the patient is likely to survive. 

The' chief difficulties that arise in the diagnosis occur in two ways : first, there are a 
few instances in which lymphatic leuka-mia has run its course without any actual increase 
in the number of leucocytes per c.mm. of blood, the diagnosis being afforded only by the 
enormous relative increase in the small lymphocytes; and secondly, children normally 
have a relatively high leucocyte count, from which it happens that lymphatic leukaenna 
may sometimes be suspected in them when it is not really present. Suppose, for instance 
a eiiild suffers from an obscure illness associated with ana-mia of the chlorotic type with 
an increase in the leucocytes up to 25,000 per c.mm. and a relative increase of the small 
lymphocytes up to 55 per cent, would one be justified in diagnosing lymphatic leukaemia ! 
One micriit be if there was general enlargement of the lymphatic glands and enlargement of 
the spleen ■ but otherwise both the leucocytosis and the relative increase in the lympho- 
cytes mio-ht be due to some other complaint, and the only means of arriving at the diagnosis 
mi<xht be by awaiting developments. It is not safe to insist upon a diagnosis of lymphatic 
leuka-mia unless there is either a very large increase in the total number of leucocytes, or 
a relative increase in the small lymphocytes up to 90 per cent or over, or both these changes 

at tlie same time. „ , , • ■ i 

Mixed Forms of Leukfemia.—.Mt hough the majority of cases of leukaemia belong 
either I., the spkno-medullarv or the Ivmphatie form, there are cases in which the symptoms 
■ind the blood changes partake of the characters of both. Either the splenic or the 
iMuphatic Glandular enlargement, or both, may be marked : there may be no ana?mia 
iintil the disease has passed its earlier stages, when the red cells and haemoglobin pass 
tliron.di the chlorotic type of changes until they reach those severe alterations characteristic 
of airaiKcmias in their last stages ; the white corpuscles show more or less increase m 
their total numbers, and the differential leucocyte count shows not only considerable 
numbers of myeloc\4es, such perhaps as 20 per cent or more, but also a great relative 
increase in the'lvmphocytes up to, it may be, 60 per cent or over. The occurrence of these 
cases of " mixed' leuka-mia would seem to indicate that there is really no absolute difference 
in kind, but rather only :. difference in type, between the lymphatic and the spleno-meduUary 
forms already described. 

Parasitic Ansemia associated with Eosinophilia.— Many varieties of the jjarasites 
that affect man produce hardly any blood changes at aU—riichocepl,ali,s dispnr. (Xryum 
vermicularis. Ascaris Jumhrkoides. Other parasites, however, produce very marked changes 
in the l)lood, and one may mention in particular Dolhriocephalus hitiis. Aiil.ilhstomiim 
d„iHlci„ih: TrichiiHi spiralis. BilliarJa liwmatohin, Filaria smigiiinis Iiominis. and not a few 
cases of hydatid disease. The ana-mia which results may be very profound, and the blood 
may exhilait all the changes described above as common to the severest anaemias. Th« 
colour index is usually low, but sometimes it is greater than 1, simulating pernicious ana-mia 
but whatever the total leucocj^tes, the differential count very commonly presents a con- 
siderable increase in the coarsely eosinophile corpuscles, and this Eosinophili.\ (p. 219) n 
association with severe aiKi-mia. is suggestive of the presence of some toxic parasite. H 
.Iocs not indicate which parasite is present, however, this being determined by caretu 
examination of the fa-ees, urine, and so forth (see Parasites, Intestinal, p. 519). 

Parasitic Ansemia associated with Parasites in the Blood.—The four best knowi 




I'lirt of ;i Mood (iirn from a uiso of splctio-meduUury ((Mikuiiiiu. wliowiiiu fivo noiitropliile mycloi-ytos. oiio fo-inophili; 
itiyeliK-ytc, three hiisophile cells, and one ltirmflo;it<'"| red veil in lulditioii to iiurnial i-orpuscU'-. 



lNIH-;\ i}V lU\r;NosfH -To facr p. 2t! 



AN. EMI A 



27 



diseases in which human beings have parasites in the blood are : malaria, filariasis, trypano- 
somiasis, and relapsing fe\er. In all these there may be much destruction of red cells with 
consequent aniiniia of the ehlorotic type. In most cases the history, particularly of residence 




■!■!• 


AUOUST.a 


r-* 


17 


16 


!^ 1 


18 


19 


„ 20 


21 
25 


l07 
106 


I:°ili^ 




!.5:i' 


•^^ 


"^ 


3; 




hn 


"E 


35 


T 


PE 


IB 


r 


M 


P 


3a 


I 


± 


M 


Z 


zni 


zUim. 


JUJiiLiiH 


JUp-Uilj! 


p,.-^ 


¥^ 


•:::\ 




^l! 




;; 


























^: 








:; 








,'-\ 




/ > 




w 


n;;;; 


t| 


;;H;; 


\^ 










:; 
--- 




;; 
















5; 






" 






'I 


»'' \ 


», / 


:i 












\.'. 
















/ 1 


v" 


i 


■101 

:ioo 

99 

~q 
■J 
. ?6 


















'. ' 1 . : ' , 












] 


'•.<-' 






^' 








.... ; r-^^i 




/ ^» 


., 


'■•' 








" ' ' ' j ' i ' '^.-•'.j /' " 


^;- I - • 


'■/ " •' 


t 


' i ' 








il 


! ,. ■ ; j , r 






" 








.i-i--l-:|::! 




/■■"J. 



irly tPiniiomturn chart i 



pliipsiMi; toy 



r> some tni|ii(;il country where the disease in fpicstion is likely lo occiu', will suggest the 
|iagnosis. and the examination of Ihc blood, cillicr fresh or. in lilms. will be coiilirmalive. 
Hclfi/tsiiiii fiTcr iisi'd lo be prcMilcnl in (ircal Hiilain. and it still occurs in cpiilcmic 
jf>rm in times of famine in association with Mnclciiiiniss. II is commoner iibroail. It is 



Its best known 
It 



■28 ANtEMIA 

<luc lo infection by the spirocliEete of Obermeier (Plate XXVJII, Fig I, p. 614) introduced 
into the body by the bites of bugs. It is a long spiral organism, 40 ^i long and 1 fj broad, 
aetivelv motile in fresh blood, but best seen in films stained with Leishman's stain. They 
first appear a day or two before the paroxysms of fever {Fig. 5). and may reach large num- 
bers. In the intervals they are not to be found. The course of the disease usually suggests 
the diagnosis, outbursts of pyrexia associated witli extreme prostration and severe illness, 
lasting about a week or rather less, alternating with intermissions of about the same 
length. There may be an indefinite number of relapses before the patient either dies or 
recovers. 

Filariasis may be latent for a long time before it produces symptoms, 
effects are elephantiasis of the legs or genital organs, with or without chyluria. 
occurs in many parts of the tropics, particularly in some of the Pacific Islands, such 
as Figi : and " in certain parts of thina. Tlie elephantiasis and chyluria are due to 
mechanical obstruction to the pelvic lymphatics by the mature worms. The blood exhibits 
more or less ansemia of the clilorotic type, with a varying degree of eosinophilia, whilst at 
certain times of the day or night the peripheral blood also contains the long but narrow 
filarial embryos (Plate XXJIII. Fig. F. p. fiU). There are probably different varieties of 
the organism, but they cannot be distinguished easily by the appearance of these embryos 
alone. Without laying stress upon generic differences, it is important that in most cases 
they are to be found in the peripheral blood only at night (Filaria barierofti nocturna);' 
(luring the day they seem to retreat into the deep vessels ; there are other cases, however, 
in whTch embryos, very similar in appearance, occur in the peripheral blood in the daytime 
and not at night (Filaria diurna) ; whilst in Filaria perstans tliey are present in the blood 
both day and night. Roughly speaking, one may say that each embryo when stretched out 
is 200 /(long and 4 to 5 /i wide, and they stain by Leishman's method. They may be found 
in the blood of patients who have returned to England after contracting the disease abroad. 

TryiJanosomiasis — the cause of sleeping siekiiess. Trypanosomes of many different I 
kinds are known to affect various animals, birds and fish, but the only one which is important 
in man is the Trupaiioxiiiiia gamhieiise (Plate XXI III, Fig. G. p. 614). It is to be found in \ 
blood films stained by I.cislmum's method months or years before it finds its way into the ! 
cerebrospinal fluid to procluie sliiping sickness. It has a large and definite nucleus about 




j.-i,,, fi. — Case of simple tertian malaria, showing the attacks occurring every thk-ij daj. 
{Clmrt supplied by the London School of Tropical Medicine.) 

its middle, surrounded by protoplasm whicli becomes jjrolonged into a relatively long un 
dulating membrane terminating in a llagellum. It is an extra-corpuseiilar organism readilj 
distinguishable when seen in its mature stage. It occurs particularly in people who havei 
been resident in Uganda or other district in which Glossina palpalis, the fly which spreads 
tlie disease, abounds. The diagnosis is much less easy when the blood contains only 
inmiature forms. It is sometimes easier to find the embryos in fluid obtained by punctm-ing 
tlie enlarged inguinal or other lymi)hatic glands often present in these patients. It i> 



PLATE V 



LYMPHATIC LEUK/EMIA 



A. # 



oo 



o o 



W 




m 



C: 



G 
O 



« 



Oo 



#i 



o 



'■"" of ^ I' 1 liln, fnmi u . ,i,p „( lv„il.l,:.li,- Wnk.vmv.K sliowini; :. hir-c rc:.>c in llu. small lympliocyte 



IXIIKV l)F I.IAi:NC)>is -7V) /,„v ;,. SS 



AX.TIMIA 



29 



irt-orthy of note tliat one variety of severe an;eniia occurring in Assam, associated with 
nTexia and enlargement of the spleen, and formerly thought to be a variety of malaria, is 
lue to a variety of trypanosomiasis in which only immature forms of the parasite (Leishman- 
Donovan bodies) have been found (Plate XX\ III. Fig. H. ji. (>14) : and here not in the 
general blood stream, but in the fluid obtained by splenic puncture. The disease is 
emied Kula-azar. 

Mdhiiia is not essentially associated with anicmia ; but in jiatients who have had 
■ecurrent attacks blood destruction by the parasites leads to considerable reduction both 
II the red cells and in the ha;moglobin, the colour index generally being of the chlorotic 
ype. The changes in the white corpuscles are described on p. ;J61. Tlie diagnosis can 
iften be surmised when a patient who is, or has been, resident in a malarial district suffers 
rem ])eriodic rigors with pyrexia. Theoretically there are two main types of the disease, 




Fi(j. 7. — Case of quartan malarial fpver, the attacks recurring every fourdi day. 
• (Chart supptwd by llic London School of Tropical Mcilicin, .} 

the terliiin. in which the paroxysms come on everv alternalc das uilh complete 
jery intermediate day (Fi«. (i) ; and the qunrUin. in which llicr.'are two-day int 
|al the paroxysms occur every fourth day {Fi<>. 7). What happens in a malaria 
^•wever, is that alter a patient has Imcii infccte.l by one set of mos,|uit(. bite 
tlian or ((uarlaii ague, he becomes infected subsctitiently upon differeni days 
*>si|iiit<>(s ujil, „t|,er tertian or (|iiartan parasites, so that there is a minglin<. 
•the cllcls (>r different sets of luematozoa. For instance, if a patient'' had 
•ifected by two tertian parasites, the one producing rigors upon .Monday \\\ 
Jiday, and Sunday, and Ih,. other attacks u|.on Tuesdav. 'I'lmrsdav. Satiin 
-mday, tins patient woulrl have a paroxvsm everv day. the Ivpe Ixiii..' tli.n spo 



■edom 
ds. so 
strict, 
ilh a 
other 
etlK'r 
'Come 
sday, 
and 
(.r as 



,,Q AX.EMIA 

,,„nMian {Fis 8). If l.o were infected by two quartan parasites, the one produeing attacks 

uln Monda;. Thursday, and Sunday, and the other upon Tuesday. Fnday and Monday, 

e oec'n-renee of the paroxysms beeon,es less regular, for the patient would haye a r.gor 

r^,n Monday, another on Tuesday, none on Wednesday, a rigor upon Thursday and Friday, 

t n.Mu. ouSatunlay. and so on. Eaeh infection by a fresh brood of malanal parasites 

1 ipli.ates the elinieal picture, until finally in those who haye been long in nialanal districts 

attacks of pyrexia may be quite irregular or even almost continuous. Kach paroxysm 

as three charac eristic stages, any one of which may last from half an hour to two or three 




(Cliarl riijtiilial hij Ihe London School of Trop 



hours.' or eyen more. During the first or cold stage, the patient shiyers w th a e^ere r.go, 
eels ;old, looks blue and pinched, but neyertheless has a rise of tempera ure to 102 K o 

loV F. The teeth chatter and the patient wraps himself up to try and keep -am Th, 
s followed by t.,e ho, staae. which begins with flushing of the face, seyere headache, pa us 
he back further rise of the temperature to 104= F. to 106^ F.. and a sensation of such he^ 
at 1 e patient throws off the clothes and calls for cooling drinks. This ends in the thi 




,,„ ., -, ■;.. of malarial fever Ulustrating severe tertian attacks alternating with mild tertian attack, due to 
double iniection. (.Chart supplied i,j Ihc London School ol Tropical Media,,-.) 

or srccnting singc. during which the skin, previously dry, breaks out into perspiration so scv. 
t ha alKthe bedclothes may be .vringing wet. The temperature now falls, and the pa . 
more or'less exhausted, sleeps, and on waking feels comparatively well except for a sens 
Takness ; he may be able to do his ordinary work until the next paroxysm comes on O. 
Ta few cases do'^nruch severer symptoms supervene if proper treatment be adopted, 
the absence of treatment, however, malaria may lead to hypeinnTcxaa (10, F-11- J 
o coma • or to a condition of algidity and collapse ; any one of which may end in dea 



The diagnosis may be confirmed to some extent bv findino that tlic inrcxial outbursts 
inninish or cease altogether under the administration of quinine, but tlic only real proof 
f the nature of the complaint is the discovery in tlie blood of the malarial parasites 
Plate XXVIII. Figs. A. B. C. D. and E. p. 614). It is important to note that the 
idnnnistration of ,|uinine renders it dillicult or impossible to (hid these in blood films and 




Fir: 10.— Case o! m»larml lever befoming complex from multinle malari:il ii.feL-tion. 
(Chavl supplird lij llie London Sc/mol of '/'ro/iiml .Valichie.) 

len the behaviour of the leucocytes (p. 8(il) mav bo verv heli)hil. .Vllnnninuria is 
.mmon. and the urine generally contains urobilin .luring aetixc malaria, ceasino- to do so 
hen the latter becomes latent : microscopically, golden brown piun.ent granules\re often 
be lound ui the centrifugali/.ed deposit : these and the urobilin together may point to 
e diagnosis when no parasites can be loun.l in the hlo.,,1. For a detailed account .,f all 




■...y, .l".'?;?'^'! \y....'J\ .1 .... 3 1 — » — 1 — r~~] — i — I — 



li 




Fiij. 11.— CImrt to illustrnte irrewilnr pyrexiii in chronic ni'ilnria. 
(Chart mijiplied bij the I^mton .fclmol of Tropical Medicine.) 

• Stages and apju-aranccs of various malarial parasil.s. leM-l„M,l<s „( |nmi<al nu-ili.ine 
mid be eons.dled. There arc two uiain types lo l„. sen in lihns slaind l.v l.cish.nans 
.."'':""■ 7^-/'"'" ""■' ""■ <rrsr,;„-f,.nn. The lallcr arc p.Mhaps th.. rarer, though ll... 
." ".MXNol malaria, particulai ly the lestivo-auluimial form met with on the West (oasi 
Alnca. arc generally due to it : the cn^eeulie parasil.s .annot !..■ misl.ak.n lorauvtlm... 
•• J Me ..nlmary t.itian aii.l ,,uartan agu.s ar.' due to III.' ring f.>ri naiasil.s alii.ir 



32 ANAEMIA 

thouoh the two types are distinct from one another, are sufheiently similar not to be 
distinouishable in films except by experts. If blood is examined at the begmnmg of the 
ri..or the stage most commonly seen is that of Plalc XXV III. Fig. B. p. 614. The two 
chief points of morphological distinction between tertian and riuartan parasites are, fnsi, 
that the pi.nnent granules are much blacker and fewer in number with the quartan than 
the tertian" and secondly, that in the rosette stage the quartan seg.nents are fewer than 
the tertian One remarkable feature about malaria is that it may remam latent for many 
years and yet recur in those who have long since returned to Great Britam from the tropics. 
What has happened to the parasites in the interval is not known, but their re-appearance 
is brought about by such conditions as general depression of health from overwork or 
worry, or as the result of some intercurrent malady. 

(B).— ANEMIAS WITH AN INDETERMINATE OR NEGATIVE BLOOD-PICTURE. 

The diaonosis of the fact of anfcmia is made by means of a blood-count, but in the 
oreat maiorit'v of cases the cause of the anaemia itself is not indicated by the blood con.l.tion. 
The differential diagnosis has to be made on other grounds. One may subdivide 6Yo»;j B 
into four sub-groups, namely. (1) Those cases in which the ana-mia is slight and in itself 
not a very prominent symptom ; e.g., in an indoor worker or a convalescent : (2) Those 
cases in which though the ansmia mav be severe, the routine examination of the patient 
d'iscovers some more or less obvious and not absolutely uncommon cause for it ; e.g., 
chronic tubal nephritis : (3) Those cases in which, though the anemia may be severe, no 
obvious lesion c-.m be discovered, but in which there is nothing about the case to suggest 
that the condition is a rare or unusual one : e.g.. chlorosis : (4) Those cases in which the 
■inxmia may be more or less severe, in which there may or may not be obvious lesions to 
Leconnt for "it, but in which the circumstances of the case suggest that the disease is unusual 
or rare ; e.g., chloionia. . 

Cases in which the Ansemia is slight and in itself not a very promineni 
symptom —It is clear that before any an-xmia that is not due to acute blood loss Iron 
intern il or external hemorrhage reaches a severe stage, it must pass tlirough a phase ii 
which' it mav be regarded as slight or mild. This group therefore really includes all the 
other crroups at some stage of their development, and the diagnostician will often label 1 1 
case to'start with comparatively mild or unimportant, when the course of events nltunateh 
shows that this was wrong. For instance, a case of pernicious ana-mia may exhibit wha 
seems to be unimportant svmptoms for months or years before the ana-m.a reaches s. 
definite and severe a stage as to be diagnosed correctly. The group now under discussioi 
is meint to include onlv such slight degrees of anemia as are themselves not important i 
the niatter of diagnosis ; for instance, in people who live too much indoors, in those wh. 
•ire convalescent from some illness, in those who suffer from chronic indigestion, constips 
tion obesitv some forms of chronic intoxication by microbial products, due to such thing 
as infective synovitis or arthritis, pyorrhoea alveolaris and oral sepsis, uterine or ovar.a , 
disease the earlier stages of phthisis, empyema, latent or deep-seated caseous glands < 
tuberculous affection of joints, vertebrae or peritoneum in children, the milder cases , 
olumbism and so on : in all these cases there may be a sufficient degree of anaemia to attrae 
some attention, but the diagnosis will rest upon other symptoms and signs than thoS'j 
connected with the blood, and in most cases the anemia will not be extreme. 

Cases in which, though the Anamia may be severe, a routine examination ( 
the patient discovers some more or less obvious and not absolutely uncommo 

*'''"*//«"L!rk«2e.-Some of the most striking cases of anemia in this group are those i 
which there has been recurrent or severe loss of blood. When the latter has been la 
bv euistaxis hemoptysis, hematemesis, hematuria, menorrhagia. metrorrhagia, metrostaxi 
nurDura or by the escape of blood per rectum, the nature of the anemia will generally 1 
'.bvious'and the differential diagnosis will depend upon the cause of the particular lienio 
rha^e in question (see Epist.vxis, etc.). One should insist upon a complete blood-count 
■ill these cases however, in order to exclude pernicious anemia, leukemia, and the otU , 
conditions in which the blood-picture is positive, lest the bleeding be due to the blood sta 
and not the blood state to the bleeding. The possibility of melena should also be borne 




I'jirl of a. blood tihn from ii l- we of iiiuliui i, !?howiriij three in;il:iriil iKinisites of tlie ring ty\ 



INDKX <>K |pi\.;\()sis -To face p. .".li 



AN.BMIA 33 

mind, for without examination of the faeces the extreme pallor resulting from loss of blood 
from such a lesion as a duodenal ulcer maj^ not be diagnosed correctly. Hcemophilia should 
not be forgotten : the way the patient bleeds excessively from slight scratches or cuts will 
generally point to the diagnosis, especially if there is a family history of a similar condition, 
males being affected more than females. The blood-i)icture in haemophilia is entirely 
negative, the ana-mia that results from the bleeding being of the chlorotic type. It is 
•sometimes stated that the result of blood-loss is to jjroduce an antemia in which the red 
corpuscles and the hicmoglobin are equally reduced, so that the colour index remains more 
or less normal. This may be true of an acute bleeding such as venesection or post-partum 
haemorrhage, but the effect of recurrent blood-loss is to produce the chlorotic type of ana-mia, 
in which the red corpuscles are less diminished than is the hicnioglobin. 

Cachexia. — A similar blood picture, namely an anemia of the chlorotic type more or 
less severe, but without anything which may be called pathognomonic, either as to the 
red cells or the leucocj'tes, is to be found in almost all forms of cachexia, whether due to 
syphilis, tuberculous or malignant disease, malaria, beri-beri and other tropical illnesses, 
oesophageal stenosis, or starvation. .\ careful physical examination of the patient and 
enquiry into his symptoms may point to the correct diagnosis ; but it is to be borne in 
mind how dillieult it sometimes is to detect phthisis, or some cases of carcinoma or sarcoma, 
even when far advanced. Sputum analysis should not be omitted ; rectal examination 
should not be forgotten ; the a;-rays may serve to detect lesions within the thorax, and 
Wassermann's serum reaction may be employed when sj-jjliilis is suspected. It is remarkable 
how little anaemia may result from some varieties of cancer, particularly carcinoma of the 
breast ; whilst other varieties, especially carcinoma of the stomach, produce progressive 
ana-mia eom|)arativeIy early. It is noteworthy that, whereas in former times the absence 
of free hydrochloric acid from the gastric juice at the ])roper interval after a test meal was 
regarded as good evidence in favour of a carcinoma ventriculi, it has now been established 
firmly that the hydrochloric acid may be very deficient or entirely absent in a great many 
other conditions also ; it is absent in almost all cases of advanced carcinoma, whether of 
the stomach or not : and in many chronic maladies associated with ill-health all the 
.secretions of the body suffer, and amongst them the liydrochlorie acid of the gastric juice. 
It follows, therefore, that it is only when the diagnosis has been narrowed down to there 
being some lesion of the stomach, that the discovery that the hydrochloric acid is very 
deficient or absent affords evidence that the lesion is a carcinoma. 

Parasitic affcclions sometimes escape recognition, even when they have led to siilHcient 
an;emia to attract attention (see Parasites, Intkstin.vi., p. 519). The two varieties most 
a|)t to lie associated with ana?mia arc Ayihi/lnslnnnini diindcnalc and Rotliriocephaliis latas. 
liilliarziri lifotialohiti may also lead to severe anicmia. but generally does so on account 
of the II.KM ATI HI A (p. -IH-J.) that it produces. I'.osinophilia (p. 218.) may suggest a 
parasitic infection. 

Certain drufix are apl lo produce annniia ol' I he simple ciiloi-olic tyjie if llicir adniiiiisi ra- 
tion is continued over a long period ; pai'licuiarly niciciiij/. ai\ciiif. lead and srdiciilrdcs. 
.Veute mereurialism is commonly assoeialed wilh stomatitis and salivation, l)ut in cliniiiic 
cases, in addition lo aiia-mia, there is apt to l)e a motor ty()e of peripheral neuritis all'ccting 
the limbs and associated with a remarkable tremor (p. 72(>), ))artieularly of the hands. The 
diagnosis is generally arrived at from the fact that the patient has been receiving mercury 
nicdit'inally, or is employed in some work in which mercury is used, for instance, the making 
of thermometers or mirrors, or the curing of rabbit skins for the manufacture of hats. 
Arsenical paisoiiiii!' seldom gives rise to ana-mia as its sole symi)tom : but it is noteworthy 
that although liipior arscnicalis is an admirable remedy for the relief of pernicious aiia-mia, 
arsenic it>(ir is also a cause of ana-mia amongst those who work in it. .\s a ruli;. in addition 
to a?i:emia there is iiiarUcd pigmentation of the skin (I'late I'JJ), and Addisorrs disease 
may be siimilated. In the latter, howexcr. the pigmentation occurs on the nuicous 
membranes, particularly of the lips and cheeks, as well as upon the skin, and this - 
though in very exceptional cases a similar |)igmentation within the mouth has been 
obser\-ed ill |)eriiicious ana-mia (see Plate \.\H. p. :V2H). and perhaiis after taking arsenic 
lor long periods — is ;dways very suggestive of Addison's dis(-asc, and the diagnosis may 
be eoiifiriiK-d by finding a slight di-grec of cosinophilia, a remarkably low blood-pressure, 
down (-\(-M to N(» mm. Ilgor less, attacks of \-omitiiig, syiK-ope, ami n-miirkahli- asl lu-nia. 

1) " ;5 



34 AN.EMIA 

If there is active tuberculosis of the suprarenal capsules, Calmette's or von Pirquet's 
reactions with tuberculin {Plate XXXl'II. p. 770), may be positive, but these two tests 
are now less relied on than formerly. In arsenical cases there may also be evidence of 
peripheral neuritis and of hyperkeratosis of the soles and palms. Analysis of the hair 
will discover an abnormally hiirli percentage of arsenic. The chlorotic type of anaemia in 
lead poisoning may be extreme, but the diagnosis will depend upon other symptoms, of which 
any or all of the following may occur : — a blue line upon the gums ; constipation ; nausea ; 
vomiting ; epigastric pains ; abdominal colic ; a tendency to repeated abortion in women ; 
peripheral neuritis, particularly of the wrist-drop type ; various cerebral symptoms of any 
degree, from mere headache or insomnia to epileptic convulsions or acute mania, or other 
serious mental signs summarised by the term saturnine encephalo])atliy : impairment of 
sight ; optic neuritis : ophthalmoplegia, chiefly affecting the sixth cranial nerve : a 
tendency to gout, albimiinuria and granular kidney, and the secondary effects of the latter. 
The absence of a blue line on the gums does not exclude lead poisoning in those whose teeth 
are clean ; nor does its presence ])ro\'e lead poisoning, for most workers in lead exhibit a 
blue line whether they have other symptoms or not. In cases of doubt, it may be necessary 
to collect an abimdance of urine, evajjorate it, and apply the ordinary tests for inorganic 
lead. The occu])ation of the ]iatient will often suggest the diagnosis. Salicylates are said 
to produce an;emia if their administration is continued for a long period ; but it is also 
possible that the anaemia may be due to the condition for which the salicylates are being 
given, namely acute rheumatism. The diagnosis is generally obvious. 

In addition to the aniemia that may result from acute rheumatism itself, there is apt 
to be pronoimced an;emia in some forms of vahiilar heart disease, particularly affections 
of the aortic valves, whether rheumatic or syphilitic. Mitral disease, particularly mitral 
stenosis, is more likely to cause polycj-thasmia (p. 533), unless there is fungating or infective 
endocarditis. The occurrence of a progressive anaemia in chronic heart cases always arouses 
suspicion of the latter ; most cases of fungating endocarditis present synijjtonis of failing 
compensation which are often very difficult to distinguish from those due to the mechanical 
effects of chronic vahnlar disease, so that it is often difficult to distinguish a heart case 
without fungating endocarditis from one in which fungating endocarditis has supervened. 
In addition to aniemia the following points would be in favour of the latter : sudden and 
radical changes in the character of the heart bruits, for instance from musical to blowing, 
and vice versa ; enlargement of the spleen ; the occiuTcnce of haemorrhages, particularly 
subcutaneous or retinal ; optic neuritis : pyrexia {Fig. 243, p. 566), whatever its type, 
provided it cannot be explained by any intercurrent affection such as tonsillitis or jileurisy 
— though the absence of pyrexia does not exclude the disease : rigors, though these are 
often absent ; and symptoms of infarction or embolism in the spleen, kidney, brain, 
intestine, retinal or peripheral vessels resulting in convulsions or paralysis ; cessation of 
pulse in one or other of the accessible arteries such as the radial, posterior tibial or 
dorsalis pedis ; acute gangrene of some part whose circulation has thus been cut off 
suddenly — a toe, or the tip of the nose for example ; the develojiment of a spontaneous 
peripheral aneurysm ; sudden hsematuria : sudden acute pain over the spleen, associated 
jjerhaps with a peritonitic rub. It is noteworthy that there is but little leucocytosis- 
in infective endocarditis. Cultivations from the blood obtained by aseptic venesection 
may serve to clinch the diagnosis, and also to indicate what seriuii or vaccine treatment 
should be employed ; though it is remarkable how often blood cultures are negative in 
these cases, even when the blood is obtained during a period of high pyrexia. , 

It is in some cases easy, but in others relatively difficult, to be sure of the diagnosis 
of subacute nephritis. Anaemia is a prominent symptom in the chronic nephritis of yoimg 
peojjle, though the reverse is generally the case in the red granular kidney of later life ; for 
the differential diagnosis, see Albuminuria (p. 9). The old aphorism of "■ the large 
white person with the large white kidney " may sometimes suggest the malady. 

Many subacute or chronic maladies associated with continued absorption of microbial 
toxins have anaemia as a prominent sj-mptom. One may mention, for instance, chronic colitis, 
whether muco-membranous, ' simple ' ulcerative, or tropical dysenteric (see Diarrhcea, 
]). 17"2) ; deep-seated suppuration acts in the same way, and one is familiar with the 
pallor of patients suffering from empyema : the development of this aiuemia after the 
crisis of lobar pneumonia, or in connection with broncho-[3neumonia, in children, not 



AN.ilMIA 



35 



infrequently suggests that an empyema lias" developed ; the diagnosis may be confirmed 
by the physical signs, but it will be clinched by finding pus when the chest is needled. 
Leucocytosis or a relative increase in the polymorphonuclear cells does not help in 
determining the presence of empyema so much as in other cases of suppuration, because 
empyema is nearly always secondary to lobar or lobular pneumonia, and in each of these 
there is also a polymorphonuclear leucocytosis. Other examples of chronic sepsis which 
may produce severe ana-mia are chronic appendicular abscess ; pyosalpinx ; hepatic 
abscess ; the breaking down of ovarian or uterine timiours ; chronic endometritis ; 
pyorrha?a alveolaris : infection of sinuses connected with bones or joints, particularly 
unclean tuberculous hi]) or knee joints ; psoas abscess ; suppurative periostitis or osteo- 
myelitis, with necrosis of bone ; secondary coccal infections in phthisis with cavitation, 
or in bronchiectasis. Chronic sepsis may produce Jardaccnus disease, which itself is also 
a cause of profound anaemia, with a peculiar pale yellowish or transjjarent appearance of 
the skin, though its diagnosis is exceedingly ditlieult in any but advanced cases. It is 
guessed at, as a rule, on account of there being a chronic purulent discharge from lung, 
joint or limb, or else severe tertiary syphilis. There may be enlargement of the liver and 
spleen, albuminuria, and a tendency to diarrhoea ; but even when all these symptoms are 
present, it not infrequently hap|)ens that the post-mortem examination shows that there 
was no lardaceous disease at all. 

Rheumatoid arthritis is an indefinite group of joint diseases which differ essentially from 
osteo-arthritis (]). S48), in that with the former there are more or less severe constitutional 
symptoms, including slight pyrexia, loss of appetite and weight, pigmentation of the skin, 
and ana-niia. The nearest lymphatic glands, e.g., the eijitrochlear when the hands are 
affected, are often enlarged and tender. The diagnosis seldom depends upon the anicmia, 
however. Probably there are many varieties of rheinnatoid arthritis which will some day 
be classified upon a bacteriological basis into those due to gonococci, streptococci, staphy- 
lococci, ])neumoeocei, JiaciUus coli communis, Spirochceta pallida, and so on. There are 
two types that are ])artieularly prone to anaemia, and these are, first, the form in which 
there is marked spindle-shaped enlargement of all the first intcrphalangeal joints in adults, 
whatever otiicr joints may be affected at the same time (p. IH'I) : and secondly, a general 
destructive affection of the joints in children, associated with emaciation, an;emia, enlarge- 
ment of the spleen and of the lymphatic glands, and known as Still's disease {Fig. l(ii), 
p. 377). (See .Joints, AtTiicxiONS of, p. 3;:17.) 



.11^ 


»_< 


»_' 


- I 


> c 


> I 


" ■(" .«. 


M I 


- c 


1" 6 


M C 










1" I 








> c 




> I 


> [ 


5-t, 


5_t 


M El> t 


« 1 


101 
lOO 


E 


= 


= 


I 


- 




z 


z 


i 


z 


= 


- 


E 


r 


E 


E 


E 


[r 


E 


E 




= 


z 




I 


E 


E 


= 


- 


Z 


= 


I 


E 


E 


\ 


I 


E 


= 


= 


= 


i 


E 


E 


E 


E. 


E 


E 


£ 


jz 


^ 


En 


E 


E 


E 


E 


E, 


^ 


P 


~A 


Z 


= 


E^ 


z 


^ 




E 


E 


E 


E 


E 


f 






I:- 


/ 


=1 


z 




L^ 


^ 




f\ 


^ 


/ 


■~, 




)i- 


M- 


/ 


•sJ 




V^ 






1^ 


^ 


^ 




^ 


Jz 




r 


^ 


h 


V 


z 


z 


Z 


z 


v^^ 


I- 


k 


_. 


~ 


- 


- 




- 








_ 




— 






- 


— 


— 


^ 


- 


— 




- 


- 


- 


— 


- 


- 


_ _ 




z 


? 


f 


z 




k 


\ 


E 


z 


E 


z 


= 


"= 


E 


= 


i 


E 


E 


z 


' 


E 


r 


E 


= 


z 


- 


E E 


• |88 76 80 88 96 76 8* 


76 84 84 84 76 80 ' 80 


80 88 84 88 72 84 104 


96 96 80 84 92 80 e4| 


.[a* 84 90 86 84- 88 80 


68 86 88 84 80,68 80 
20^20 J2^0 .24-'20[26 


90 92 

24-J20, 


96'92 88 68 100 


84 


88 84 76 72 90 96 


" 


24.|24- 24-,24.:24.j20 20 


20 ,20:24, 20,24- 


24 


20,20 20,24|24^4 


■ 


2* 124-126 j24-|24-'|22 ,2* 


22 20|24.|22|20 22 [26 


22[24.|24-]20[24j24r26 


26l20|20|20'24|26'20| 



Thosis of till' In 



Cirrhosis of the liver sooner or later leads to ana"mia of the chlorotic type, although' in 
the earlier stages the alcoholic jiatient may have a rubicund complexion ; by the time 
the ana-mia is pronounced there will almost certainly have been other .syni])toms of the 
complaint, particularly II.kmatkmksis ([). 'ifi.T), Jalnuicf. (p. :!21-), or Ascitks (p. i'.i). 
Patients with cirrhosis of the liver often have some evening pyrexia {Fig. I'J), and they 
tend to undue pigmentation of the skin. 

Ilil/icrlailalion is a pniininent cjiuse of anu-mia and general ill-health, especially in 
women in towns. The cause for prolongation of the period of lactation is often an idea 
that pregnancy will not recur whilst the last infant is being suckled. The diagnosis is 
generally obvious if its j)o.ssibility is borne in mind. 



36 AN.milA 

Gastric ulcer, or rather the symptoms which are often stated to be those of gastric 
ulcer, is frequently associated with anaemia ; the latter in a few cases is the result of direct 
loss of blood by H^matemesis (p. 268), or, in the case of duodenal ulcer, Mel^na (p. 75). 
A duodenal ulcer may sometimes simulate gastric ulcer, but more often it produces symptoms 
which are apt to be mistaken for gall-stones, the pain being referred to a spot about an inch 
below the tip of the ninth right rib. As a rule the pain in cases of duodenal ulcer bears a 
definite relationship to food, being greatest when the patient is beginning to be hungry, 
and relieved by the taking of food. Gastric ulcer, on the other hand, is much more difficult 
to diagnose, for even when the patients have suffered from epigastric pain coming on 
inmiediately after food, from vomiting whicli relieves the pain, and from one or more attacks 
of hoematemesis, it is possible for the latter to be due to generalized oozing froin the gastric 
mucosa — '■ gastrostaxis '" — rather than a definite measuraljle ulcer. AVlien there has been 
no hiematemesis the diagnosis is still more dilficult, though it is noteworthy that in nearly 
half the cases in which the presence of an ulcer has been proved by operation there has been 
no history of hsematemesis. It was formerly stated that gastric ulcers are common in the 
female sex between the ages of fifteen and thirty, especially in the unmarried and the 
anaemic : notably amongst the servant class ; operative demonstrations of gastric ulcers, 
however, seem to show that they are really commoner in later life, and affect men as often 
as women, so that there is a very decided possibility that the gastric symptoms of ana?mic 
women are not in fact due to idcer. One meets with patients who have pain the moment 
they take food, in whom vomiting after meals is persistent, in whom the diagnosis of gastric 
ulcer would certainly have been made in former years, but in whom that diagnosis is made 
now only with considerable caution. It has become increasingly recognized that the 
vomiting and the gastric signs arc often due to the anaemia itself, and result from anaemic 
<lilatation of the heart. In diagnosing between this condition and that of true gastric 
ulcer, one of the best plans is to put the patient to bed, and when she has been recumbent 
for twenty-four or thirty-six hours, to see what is the effect of giving her fidl diet. Full 
diet will be borne quite well in cases of severe anaemia associated with gastric symptoms 
without ulcer so long as the ]5atient remains in bed ; but if she gets ujj and returns to work 
before the anaemia is cured the gastric symptoms come on again directly. The vomiting 
and the epigastric pain seem to be related not so much to food as to work in these cases. 
When there is an ulcer, however, an attempt to adopt full meat and vegetable diet on the 
second day of resting in bed nearly always fails if there have been severe symptoms up to 
that time. 

Conditions in which, though the Anaemia may be severe, no obvious Lesion can 
be discovered, whilst at the same time there is nothing to suggest that the case is 
a rare or unusual one. 

Chlorosis is almost the only malady which conies under this heading, if one includes the 
milder ansemias of girls and young women as well as the severe cases of yellow-green sickness 
to which the term should strictly speaking be limited. The cases of anaemic vomiting just 
discussed might also come under the same heading. Chlorosis and simple chlorotic anaemia, 
without obvious organic lesions, are affections of the female sex — absent before puberty 
and common immediately after, seldom lasting after thirty years of age, and generally not 
so long ; cured as a rule by marriage ; never fatal even when severe ; an affection of all 
classes, but mostly of indoor workers such as servant girls, and not often affecting those 
who are employed in outdoor jjursuits. The diagnosis is generally easy. The patients are 
comparatively well covered though they often eat very little. Emaciation is rare in 
chlorosis, and this is probably due to the fact that the blood is less deficient in quantit\ 
than diluted by excess of water. The leucocytes are normal both in total mnnber and in 
differential count. The red corpuscles are often much less diminished than might be 
expected from the appearance of the patient, the chief feature of the complaint being the 
great reduction in the haemoglobin, so that the colour index may fall to 0'5, O'i. or even 
less. As the condition improves the red cells return to normal fairly quickly, and the 
hsemoglobin rises steadily but less rapidly. The way in which the patients react to treat- 
ment by rest in bed, by the giving of iron, by keeping the bowels open, and by living in a 
sunny atmosphere, is remarkable, and helps to clinch tlie diagnosis in any case of doubt. 
It has been mentioned above that there are many blood changes which are common to 
severe ana?mias ; it should be noted that even when the haemoglobin has fallen to 30 per 



AN.EMIA 



37 



cent of normal in a sc\ere case of chlorosis, the changes in the blood-cells enumerated on 
page "^2 seldom appeal'. Chlorosis, more often than any other form of anaemia, leads to 
hicmic cardiac bruits, ])articularly a blowing systolic bruit in the pulmonary area and a 
briiil (le dkible in the neck. The patients are often constipated, are apt to suffer from 
menstrual irregularity, particularly amenorrhaca. which may last for months, and a tendency 
to oedema of the feet. The viscera are generally normal. Chlorosis, unlike many other 
forms of severe anicinia. seldom produces albuminuria. 

Cases in which the Anaemia may be more or less severe, in which there may 
or may not be obvious lesions to account for it, but in which the circumstances of 
the case suggest that the disease is unusual or rare. 

Iliidal.iii'x ilisainc is often spoken of as though it were an affection in which the blood- 
ci^unt indicates the diagnosis. This is not the case, however, the blood changes being 
merely negati\e, though a blood-coimt is essential in order to exclude leuk.tmia by finding 
that there is no leucocytosis. At first there is no anaemia ; later there is progressive anaemia 
of the chlorotic type, with finally all the changes in the red cells common to the severe 
ana-mias (p. 22). There is no leucocytosis, or none of 
moment. The differential leucocyte count may be normal ; 
more often, however, there is .some relative increase in the 
lymplK)cytcs with proportionate relative diminution in 
the ])olym<)ri)lionuclear cells, and when a large iiumliir of 
white corpuscles are examined occasional myelocytes and 
one or two ba.sophile corpu.scles will be detected. The 
diagnosis is made from the enlargement of the Lymphatic 
Gla.vds (p. 377) and of the Splken (p. 63.5). 

Splenic (itKvniid is a malady in which there is con- 
siderable enlargement of the spleen, progressive annemia 
of the simple chlorotic type, and no other very obvious 
evidence as to what is wrong with the patient. It is 
])robablc that more than one condition is at present 
labelled splenic an-,cmia : a considerable number of the 
cases turn out ultimately to be cirrhosis of the liver 
(p. fi33), in which ctilargement of the spleen happens to 
have been the first symptom to attract attention, very 
likely years before the other effects of cirrhosis manifested 
themselves. AVhen splenic anaemia is the original diagnosis 
in a case which ultimately proves to be cirrhosis of the 
li\(T, the condition is often spoken of as linutVs disease. 

.Iphistir (iiKVitiid has been mentioned above (p. 24), 
and there are a considerable mnnber of obscure cases of 
severe aiueiiiia to which up to the present no delinile 

lalirU can Ik allaclicd. Some of tliesc sinuiialc pcrnicioiis anaiiiia. hut al 
the lallii- in liasiiig a colciui' index peisistciil ly liss lliaii 1. Due can only i-i 
as severe .iTid even fatal un-named anarnias. 

l'siitdi)-i(uk(rniiii iiiftinlion is a t'oiulilion in wliicli ciini-mcins (■nlargcin<nl < 
takes plac<- in a young child or infant {Fifi- 13), associated as a rule with more or less ascites 
and enlar;;cmciit of the abdomen. So great is the splenic eidargcmcnt sometimes that the 
condition at first suggests Icukicmia ; but when a blond-count is made, although the red 
• •ells niay be very nuich diminished an<l exhibit all the changes characleristic of severe 
aniemia, there is no extreme leucocytosis, so that the condition cannot be classified as a 
leuka-mia, and hence is termed " pseudo-leid<a'mia itd'anlum ; ' it has also been called ' i-im 
Jid.sili's tlisc/ise.' It generally begins at an age ol' less than two years. The liver is enlarged, 
bul less so than the spleen. 'J'licre may be severe haemorrhage from the mucous membranes, 
anrj liicrc js (irirn |MricMlic |iyie\ia. The disiaM' may l)e mislaken for rickets or for <nn- 
gcnilal syphili^ : iriiliiil some aulhorilies lliink llial il is realiv due hi iiiie or oilier <ii- liolli 
of lliese causes in an exaggerated degree. W'liellier this is sii in- nol. the pi-ognosis is lair 
even when the ana-mia has reached a severe degree. 'I'he asiilcs rna\ disappear, the huge 
KpU'cTi iTiay become restored to its normal (lim<'nsions, and llic palieni recover coiTiplelely 
in llic course of monllis. 




I dilTer fn 
■Icr |.> lli( 

,ril,rspl. 



38 



AN.^MIA 



Myxcedema is a condition which may be mistaken for simple anremia, and consequently 
it is apt to be overlooked, particularly at that stage which merits the term ' hypothyroidism ' 
rather than myxocdema. It is an affection of women ratlier tlian of men ; it conies on 
\'ery slowly, and sometimes it can be diagnosed only by watching the beneficial effects of 
thyroid treatment. There is generally excess of gelatinous subcutaneous tissue, which 





Fig. 15. — My-xcedema : the character- 
istic facies, illustratitiff tlie broadeniiis of 
the features ami the niahir flush. (Com- 
pare Fi'j. It.) 



gives the patient a puffy or a?(lematous appearance, especially in the face [Fig. 15), hands 
(Fig. 10), and lower limbs, so that not a few cases are mistaken for nephritis. The urine 
is copious and of low specific gravity, but usually does not contain albumin : thovigh in 
some cases there is sullicient albimiiniiria to make the case still more like one of Brights 
disease. The ajiiiarent a'deiua docs not i)it on pressure, or pits far less easily than it would 

if it were ordinary oedema ; the 
skin becomes thickened, and the 
hair decreases in quantity and 
becomes brittle. Physical move- 
ments are lethargic, and the in- 
tellect dull, so thiit there is slow- 
ness of action bt)th of body and 
(if mind, symptoms that disappear 
in a remarkable way under thyroid 
treatment. In some cases the 
mental symjjtoms predominate to 
such a degree that some form of 
flelusional insanity or dementia 
may be diagnosed, or even a 
cerebral tumour. The chlorotic 
type of amemia which accom- 
|i;inics myxocdema may be masked 
liy a local flush over the malar 
bones, not unlike that of mitral 
stenosis. 

Scurvy is a rare disease which 
may lead to the most ])rofoimd 
anaemia, though it seldom does so 
without also producing extensive haMnorrhage into the skin, beneath the periosteum of 
the tibia- or other bones, from mucous membranes, and especially from the spongy and 
ftrtid gums. It is not common now-a-days, except in a mild form in children, — scm~vii- 
rickctfs or Burloiv's disease — in which tenderness of the bones associated with antemia, 
often mistaken for rickets is the main sym])tom. The tenderness in question is due to 




ANURIA 39 

local sub-periosteal hiemorrhage, and the vfiCy in which the complaint rapidly gets better 
under suitable treatment with fresh vegetable diet helps in clinching the diagnosis. Tlie 
severer forms of scurvj' are due to prolonged de])rivation of fresh food, such as is rare in 
modern practice, though it used to be common on board ships. 

Chloroma is a very rare affection, related to lymphatic leukaemia on the one hand and 
to lympho-sarcoma on the other. It is associated with the formation of multiple tumours, 
especially in connection with bones, and a progressive and severe ana?mia of indeterminate 
tyi)e. The condition is fatal, and the diagnosis is at once suggested by the green colour of 
the nei)])lastic dcpi'sits. Ilerberl French. 

ANjCSTHESIA. -(See Sensatiox, AnNoitMAi.niKs ok. \). fiOt.) 

ANALGESIA. — (See Sens.vtiox, ABNomiAi.iTiES ov, p. COl.) 

ANASARCA. (See CEdema. p. 411.) 

ANKLE-CLONUS is best elicited when, the patient lying on his back, witli his knees 
slightly Hexed, the ob.server quickly, but not violently, dorsiflexes the foot, the liand being 
api)l)ed along its outer border in such a way as to keep it well outwardly rotated. The 
result, when ankle-clonus is present, is a scries of rliythmical jerks at tlie ankle-joint. a[ the 
rate of al)out 7 per second — fite contractiniis coiiliiiiiiHii "x /"",2 <"'■' the pressure is iiiiiiiilaiiiril. 
The last proviso is inii)ortant. because it often ha|)pcns that a few ankle-jerks are olHained. 
varying in number from two or three to as many as twenty or thirty, but gradually tailing 
off and ceasing, although the pressure on the sole is maintained. This is sometimes spoken 
of as a ■• tendency to ankle-clonus,"" but for clinical purposes it is not ankle-clonus at all, 
and indicates nothing more tlian hypersensitiveness of the nervous system, and not organic 
<llsease. .\nklc-clonus. on the other hand, denotes changes in the corresponding crossed 
pyramidal tract, and it is to be expected in association with increased knee-jerk and extensor 
plantar rellex. Its chief value lies in determining between functional and organic exaggera- 
tions of the knee-jerk ; tlie latter may be very brisk as the result of pure nervousness, but 
if it is associated with either an extensor plantar reflex or ankle-clonus, or both, the exaggera- 
tion is due to organic disease of the upper neuron, liemiplegie or paraplegic as the case 
may be. Whereas. Ii<)\ve\er. the presence of maintained ankle-clonus is conclusive proof 
of an upper neuron affection, the absence of such eloiuis does not exclude such lesion ; 
ankle-clonus is not met with until there is a relatively large amount of lateral column change ; 
it comes later, as a rule, than the extensor ])lantar reflexes. Herbert French. 

ANOSMIA. (See SMi;t,i., AiiNoiniAi.iTJi-.s oi'. p. (ill.) 

ANURIA — :)r suppression of urine must lie <listinguislir(l tmrn reletilidii iif urine. 
\\\ which urin<- is secrete;! from the kidneys, but is rclaincd in I he hladdcr froni scinie 
lesion causing obstruction to the urethra, such as urethral stricture or prostatic obstruction 
ill the male, or pressure or dra;) upon the iirellira by !i large pelvic tumour or a retrovcrted 
gravid uterus in the female. Ketention of urine may also occur without urethral obstruc- 
tion in various forms of disease of the spinal nervous system aliccling the lumbar centres. 
In retention of urine there is pain above the jiiibes, eonstani and urgent desire to pass 
urine, and the distended bladder forms a tense, oval, dull tumour almve the piibes in tlie 
middle line. In many cases a previous history of obstruction (o I he urinary How will be 
oblained. wliilsl in (itlicrs the involuntary dribbling nf urine I'niin llic urelhra from an 
o\(r-ilislcnilc(l liluldcr at mice ilislinuiiishcs the cusc IVniii one iif aiiiiiiM. 

CALSKS or .vxnuA. 

A. Oljslniilive : — 

Caleulus in kidney or ureter 

\'esical carcinoma iiiMplviiig Ihc iiicdiic ciriliees 

I'tcriiie carciiKinia 

Large pelvic or aliiliuiiinal I iiiiKnirs. 
II. — \(iii-i)lislrii(liif : 

'I'oxic, lia'ma|(ij;cn(iiis (ir asceiiiling. 



40 ANUBIA 

In renal disease, nepliritis. lardaceous disease, tubereulosis, polycystic disease, 
suppurative pyelonephritis 

Reflex, after operations or trauma, or the sudden emptying of an over-distended 
bladder. 

In jjoisoning from mercury, lead, phosphorus, oxalic acid, cantharides, or 
turpentine. 

In severe collai)sc. 

Hysteria. 
Anuria may occur and be complete without any other symptom, and it is remarkable 
that in the obstructive forms, especially with calcidus, anuria may be complete for several 
dajs without any other symptom — latent urtemia. In the non-obstructive forms, anuria 
may be accompanied from the onset by the various symptoms of uraemia, such as vomiting, 
convulsive muscular twitchings, dyspnoea, and headache. In the obstructive form there 
may be total absence of any urine secreted, or a small quantity may be passed of low specific 
gravity, and containing very little urea or solids. Albumin is absent unless there be hsema- 
turia or cystitis, when pus may be present also. The patient may com]3lain of aching in one 
or both lumbar regions, but, with the exception that no m-ine is passed, seems to be in 
ordinary hcaltli. The appetite is good and the mental state clear ; but after a variable 
period, from seven to ten days, the patient becomes drowsy, the tongue dry, temperature 
subnormal, apiietite deficient, and pujjils small. There may be muscular twitching ; the 
drowsiness gradually becomes deeper, without any true uremic convulsions, and death may 
be postponed for as long as twenty days from the onset of the anuria. This sequence is very 
different from that seen when anuria occurs from non-obstructive causes, when there is 
frequently marked distin-bance of the nervous system : headache and giddiness are followed 
rapidly by convulsions, delirium, and dyspntra. with vomiting and small pupils, the patient 
rapidly becoming comatose and dying in a few days. 

^.—OBSTRUCTIVE ANURIA. 

Calculous Disease is the most frequent cause of obstructi\e anuria. It may occur 
at any age, but is conunonest in men of about forty. Suppression of urine may arise from 
the impaction of a small calculus in the ureter of a kidney which is practically normal, or 
may be due to the total destruction of the renal secreting substance, which has progressed 
gradually and without marked symptoms. Between these two extremes there may be 
many stages, and the two conditions, namely, ureteric impaction and renal destruction, 
may exist at the same time. Clinically, it is rare for calculous anuria to arise from simul- 
taneous blockage of both ureters by calculi ; it is less uncommon to find that one kidney 
has been destroyed by ]>revious disease, the ureter of the remaining organ then becoming 
obstructed by a stone. Exceptionally, the blockage of one ureter may cause reflex suppres- 
sion of urine in the other kidney, especially if the function of the latter is impaired already 
by disease : but in these cases the anuria is usually temporary. Calculous anuria may occur 
suddenly, and in patients who are apparently in good health, for it is no imcommon thing 
for a patient to go on in good health when he jsossesses only one functionally active kidney, 
the other ha^'ing been destroyed by slow disease, or being absent : or there may be a history 
of ]}re\ious linnbar pain, ha?maturia, pyuria, or the passage of calculi. At the onset of 
anuria there is usually pain in the lumbar region along the course of the ureter of the side 
most recently affected ; it commonly lasts a day or so and then subsides, or it may last 
throughout the period of anuria. In addition, there is frequently a constant desire to mic- 
turate, although no urine is passed, or if the anuria is intermittent, urine of pale colour and 
low specific gravity, sometimes blood-stained, may be passed. If the anuria remains 
complete, no other symptoms may occur for several days, a feature which is common to the 
obstructive forms of anuria, but is in marked contrast to the non-obstructive variety. After 
a period of anuria lasting from seven to ten days, the patient becomes drowsy, the tongue 
is dry, there is disinclination for food, and the general symptoms of uraemia may come on ; 
but in many cases the patient may die before any symptoms of iirremia occur. Thus, it is 
usual to speak of a tolerant and a urcemic period in obstructive anuria. The tolerant stage 
of obstructive anuria may be even further prolonged if the fimctional kidney be already 
hydronephrotic from previous intermittent obstruction, even to twenty days. The sudden 



ANURIA 41 

obstruction to the urinary flow in a comparatively normal kidney causes complete suppres- 
sion, whilst a partial or intermittent obstruction causes dilatation of the kidney. It such a 
kidnej' be the fimctionating organ, and become completely obstructed, the dilatation will 
increase ; and a lumbar tumour may be palpable. If there is pain on pressiu'c over the 
kidney, or aloni; the coiu-se of the ureter, the diagnosis is strengthened, or it may be decided 
to settle the diagnosis by immediate operation. In some cases in which one kidney has 
been destroyed gradually without pain, and anuria occurs, there may be great dilliculty in 
determining which of the two kidneys is the functional organ which has recently become 
obstructed ; in these cases it is a good rule to operate ujion the side on which the pain has 
occurred most recently. If the patient is not too stout, palpation may detect a distinct area 
of pain over a calculus impacted in the course of the ureter : or on careful rectal or vaginal 
examination a calculus impacted in the vesical end of the ureter may be felt. If the case is 
seen early, evidence of ureteric calculus may be obtained by the cystoscope, wlien the ureteric 
orifice of the obstructed side may be seen to be congested or ecchymosed ; or a ureteric 
bougie impermeable to the Rontgen rays may be passed into the ureter and a skiagram 
obtained, though it is only exceptionally that this can be carried out. Operation upon the 
side of the recent pain may be urged strongly, when the kidney can be opened and drained, 
and opportunity taken to explore as much of the m-eter as can be felt by the parietal incision 
and bj' catheterization from above. 

Anuria from Vesical Carcinoma implies that either both ureteric orifices are 
involved in the disease, or tliat the ureteric orifice of the only functional kidney is implicated. 
The condition is uncommon as a pine oljstructive anuria, for in most cases the kidneys ai'e 
already the seat of changes due in part to the back pressure and in part to sepsis, so that 
when anuria terminates a case of vesical carcinoma, it is more often due to renal disease 
than to ureteric obstruction. If the bladder has remained uninfected by septic organisms, 
the gradually increasing ureteric obstruction may first cause hydronephrosis, so that when 
the obstruction becomes com])lete the renal distention may increase quickly, and the sym- 
ptoms of ura?mia be delayed. In cases arising from vesical carcinoma, it is very rare for the 
anuria to occur before symptoms of vesical growth arc a|)])arent, such as hirniaturia. pyuria, 
increased frequency and ])ain on micturition; but in the infiltrating tyj)e of carciiionia, 
hicmaturia and frequency of micturition may be absent for a long time. In all cases, careful 
vaginal or rectal examination will detect infiltration and thickening of the base of the bladder, 
and the growth can be seen through the cystoscope (Plate A'l'/, Fig. F. p. "284). 

Uterine Carcinoma. — .Anuria is fre(|uent in the tenniiial stage of uterine carcinoma, 
when tlic growlli lias extended into the cellular tissues of the l)road ligament and involved 
the terminal portions of the ureters, or when the orifices of the latter are implicated in the 
direct infiltration of the growth into the bladder base. In the majority of cases dying from 
uterine cancer in the inoperable wards of the I-ondon Cancer Hospital, the kidneys are 
found to be hydronephrotie. the renal pelvis dilated, or the renal .secreting tissue sclerosed. 
a])art from the fre(|uent infeetion with septic micro-organisms. In all cases the growth 
has rcacheil an adxanccd stage, and (he disease has been apparent, but it has been recorded 
that anuria has occurred before the paliciil lias coinplaiiud of any symptom pointing to the 
uterine condition. 'I'liese eases iniglil simulate olhei- I'onus i>[ ohslruclive anuria. l)ul the 
diagnosis woulil be apparent iipoti \agirial examination. 

Pelvic or Abdominal Tumours, such as iilerinr lihroinx cimal 
ala. may cause anuria from direct pressure on I he imcIcis. cs|iccI;iII' 
is iiupacted in the pcKic ca\ity. 'I'lie cause ol the anuiia will be a 
of the abdomen and of the peKic organs. 

/<.— NON-OBSTRUCTIVE ANURIA. 

MarUcd iliiiiiiiiil icm in Ihc aiiKiuiil nl urine or ciini|ilclc anuria may occur williiiMt 
obstrucli\c Icsiiiii cil llir iirin.ny a|i|i:MMl lis. due in many inslanccs lo disease of llie iciial 
secreting tissues. In iniiiiy (il llicsc ciiscs the symptoms dilfer reinarkalil\' from lliose 
seen in o))slrueti\c iiiiiiiia. in llial llic anuria is aci ompaiiied by symptoms of uriemia in a 
sliorl time, and not alter an inlcr\al of days as in the obslrueli\-e eases. Anuria may occur 
under eerlain loxic conditions, as in acute fe\'ers. or in acute poisoning by mercury, lead, 
phosphorus, or I iirpciil inc ; the liislorv and accom|)anying syniploms of such cases arc 
usiiiilly siiHicienl lo |iiiinl lo llie naliirc of the urinary siq)pression. 



o\ i 


iirian carciiinm- 


pai 


•1 (it IIh' tumour 


■nt 


on r\aiiiiniiliiin 



42 ANURIA 

Anuria in Renal Disease. — In acute nepliritis. anuria may occur early or after the 
disease is well established, and is usually accompanied by marked disturbance of the nervous 
system. The sudden onset of the disease after exposure to cold, or in the course of an acute 
specific fever such as scarlet fever, enteric, or pneimionia, or in hicmatogenous renal infec- 
tions, associated with pallor, backache, pulliness of the face and ankles, and slight pjTcxia, 
together with the small anioimt of urine jiassed before the suppression becomes complete, 
are points all suggesting acute nephritis. If the urine has been tested before the onset of 
anuria, it is often of reddisli-brown coloiu- from the presence of blood, and contains abundant 
albumin, together with renal, epithelial, and blood casts. In chronic nephritis, anuria may 
iKcur as a late symptom in the disease, and is occasionally jjreceded by a period in which 
polvuria is marked. Anuria in chronic nephritis is accompanied by prominent symptoms 
of unvmia. such as headache, giddiness, convulsions, stertor, and coma, and unless the flow 
of urine is re-established quickly, death ensues. The previous history of the case, high 
arterial tension, cardiac hypertrophy, retinal changes, and signs of baek-])ressure, with or 
without ascites and anasarca, will point to the nature of the anuria. In other diseases of 
the kidney, such as lardaccous cUsease, suppurative pyelonephritis, or bilateral tuberculosis, 
anuria may be preceded by general failing health, with loss of apiietite. subnormal tem- 
(lerature. a dry brown tongue, headache, increasing pulse-rate, hiccough, and attacks of 
dyspna-a : frequently there may be polyuria before suppression occurs. In these cases the 
anuria is terminal, the condition of the kidneys having been known |)reviously. With the 
occurrence of anuria there may be great restlessness, with muscular twitching, loss of 
sphincteric control, convulsions, and a gradual la])se into coma. 

Poli/ci/slic disease of the kidneys frequently terminates in anuria and ursemia. but the 
diagnosis of the disease has ])robably been arrived at ])reviously. The symptoms resemble 
in a great measure those of chronic nephritis, with the exception that ascites and a?dema of 
the extremities are imcommon. Headache, flatulence, and digestive troubles, sickness, anrl 
general lassitude are symptoms of renal inefHciency, whilst arteriosclerosis, a bilateral renal 
tumour, and a low-speeilic-gravity urine in increased quantity, would suggest ])olycystic 
disease. ILvmaturia is the lirst symi)tom in not a few of these cases. 

Anuria following Operations or Trauma. — .Anuria may occur in patients who have 
underuone an (iperiiticm and who are the subjects of renal disease, or may occur occasionally 
even when no renal disease is jjrescnt. .\ny extensive operation which involves a good 
deal of shock in a patient with renal disease, or in whom the kidneys have been subjected 
to back-pressure, as in uterine myomata, may succumb to anuria unless apjiropriatc measures 
are imdcrtaken : even an apparently trivial operation on the urinary organs may cause acute 
suppression of urine. This must be difl'erentiated carefully fniin the retention of urine in 
the bladder often seen after operations such as for ha-morrhoids or for hernia. Acute 
svippression of urine may follow operations upon the lower urinary tracts, such as the passage 
of instruments, or the performance of internal urethrotomy. Anuria is particularly liable 
to occur when a catheter is passed to relieve an over-distended bladder in a ease of prostatic 
enlargement or urethral stricture, the kidneys being already distenrled from back-pressure 
or infected with septic processes, and it must be laid down as a golden rule, that if a catheter 
is passed in these cases, the urine must be withdrawn very gradually. .Anuria following 
operations upon the lower urinary tract is diagnosed by the direct relationshi]) between the 
operation and the onset of symptoms : by the rigors, pyiexia, and the profound jirostration, 
rapidly followed by convulsive movements and coma. 

.Anuria may also occur in the severe collapse following an injinv, in the late stages of 
cholera or i/cllinv fever, and occasionallj- as a manifestation of hysteria. It may be simulated 
by a iiuiliiigfrer. li. II. Jocelyn Swan. 

APHASIA. — (See Spekch, .Abnormalitihs of, p. (i\Li.) 

APHONIA. — (See Speech. Abnormalities or. jj. (i2S.) 

APPETITE, ABNORMAL.— .Vppetite may be: (1) Increased: (2) Diminished; 
(3) I'rrverlcd. 

Increase of Appetite sometimes occurs in cases of hyperchlorliydria. The general 
condition is then well maintained, there is usually pain or discomfort in the later period of 



ASCITES 43 

digestion, relieved (temporarily) by the takinsi; of more food. A test meal shows excess of 
hydrochloric acid. 

In (lifihetes. especially in its earlier stages, there is often an abnormal craving for food : 
but in si)ite of large meals the patient wastes. Kxamination of the urine will establish 
the diagnosis. 

Itilcslinal parasilcs (round-worms and tape-worms) are believed to be a cause of excessive 
ii])pctite in some cases. This is doubtful : but in any ease the point can always be cleared 
up l)y giving an anthelmintic. 

In some cases of Injsieria an excessive ap]jetitc is ])rescnt (bulimia). The patient is 
usually a young woman, and other stigmata of hysteria are present. 

Diminution of Appetite occurs in many forms of dyspepsia, especially when associated 
with a lessened gastric secretion. Thus it is almost constantly present in gastritis. exce])t, 
]3erha]}s. in the acid form. If renal disease, advanced mitral disease, or cirrhosis of the 
liver be present, secondary gastritis may be diagnosed. If there be a history of the abuse 
of alcohol or tobacco, or of indiscretions in diet, or if there be a marked defect of the chewing- 
apparatus, there is probably primary gastritis. The tongue Avill probably be furred, and 
a test meal shows diminished acidity and probably an excess of mucus, but the examination 
of the stomach is otherwise negative. (See also Indigestion, p. 317.) 

Loss of ajjpetite is also an early symptom in eases of gastric carcinoyna, and should 
lead. cs])ecially in elderly subjects, to careful examination for other signs of that disease. 
There is fre(|uently a special distaste for meat in such cases. (See Indigestion, p. 31(>.) 
In children a jirofonnd anorexia is sometimes an early symptom of tiibercidosis. 

In hysterical young women complete disinclination for food {a)wre.ria nervosa) is some- 
times met with. The diagnosis is based upon the absence of other causes of the symptom, 
the presence of other signs of hysteria, and the history of mental or emotional shock. The 
loss of appetite in such cases may amount to a complete refusal of all food, and the jiatient 
may emaciate to a dangerous degree. Obstinate constiiiation is usually present as well. 
.Mlicfl to these cases is the loss of appetite which occurs in mel;'.ncln)!ic forms of insaiiiti/. 
In such a case delusions may be present. 

Perverted Appetite may occur in the course of prcgiiaiicji. and is of no special signili- 
oanee. It is met with. too. in nervous, anaruic children, in whom it often takes the form of 
<lirt-eating (jiica). Here. also, it is not a sign of any diagnostic value. Perverted appetite 
is also a common occurrence in insanity : but other evirlence of mental disturbance is always 
present as well. Nnhcrl lliilihisdii. 

ASCITES, or the aceunuilation of serous fluid in the Dc rittineal cavity, is not a disease 
in ilself. for it may be produced by a great variety of conditions. It is easy to determine 
its precise cause in some cases : in others it may be almost impossible to say during life 
what is the primary condition. One may discuss (1) lis jihi/sical signs: (2) IIikc to 
ilislingnisli it from ollnr coiiilitiiins ichicli nun/ sininlatc it : (3) .1 rlassipril list of its 
ciiKsfs ; (4) The eliief points uiiicli will Inlp in arriving al a rorrrcl differrntinl diagnosis in 
a ji/irlicniar ease. 

1. PHYSICAL SIGNS. Inspection.— The abdomen is distended uniformly, the degree 
varying with the ainouiil of lluid. If the <|uantily is large, and its accumulation has 
been rapid, the abdomen is more or less globular, the urnliili<'al ngion being the most 
prominent,. The skin is tense and shiny, and there may be lineu' alhieantes. If the (|uantity 
of ihiid is large but its accumulation has been gradual, bulging of the Hanks is more marked ; 
the Iciucr rihs may be pushed outwards, and the epigastric angle widened. If the (piantity 
of lluid is small, only a slight bulging of the Hanks may be noticed. The a|>pearanee of the 
ahdotuen depends a good dc.il on the position of the |)alient. If lying on one side, the most 
dependent part is the most prominent, owing to the lluid gravitating to that side of the 
abdomen. If the jiatient stands or sits upright, the hypogastric and iliac regions will be 
most bulged. The umbilicus becomes stretched transversely and Hush with the surface, 
or even protruded ; it retains its position in the median abdominal line, and remains nearer 
to the pubes than to the ensiform cartilage. In tiH)ereulous peritonitis the skin in its 
inunediate neinlibourliood may be reddened and (edematous, or there may be a fa'cal 
lislula lure. In cirrhosis of the li\-er the veins around the mnliilieus are said to be dilated, 
liul llir s(i. .■ailed ■ eapiil inc-dusa' " is rare. The siiperliciid \(ins :dl over I lie iilMlorncn and 



44 ASCITES 

lower part of the cliest may be dilated, the blood flowing in an upward direetion, this reversal 
of the stream occurring mainly when the inferior vena cava is oljstructed. either by the 
tension of the ascites or by something related to its cause. (See Vkins. Varicose Abdom- 
inal, p. 748.) The abdominal respiratory movements may be absent or much diminished. 
The cardiac impulse may be displaced upwards and outwards. The legs, thighs, and 
scrotum may be cedematous, and so may the loins. 

Palpation. — The abdomen may be anything between quite flaccid and very tense. 
A fluid thrill may be obtained by placing the hand flat against one iUink and gently flicking 
the other with the fingers of the other hand ; the possibility of a thrill being transmitted in 
the abdominal wall should be eliminated by getting the patient or an assistant to place the 
side of his hand on the front of the abdomen, so as to stop the mural thrill at the point 
of contact with the abdominal wall. If the above precaution is taken, anri a thrill is 
obtainable, it denotes the presence of fluid. 

If the liver or s|)leen has enlarged it sinks backwards, so that between these organs 
and tlic abdoiiiiniil wall a layer of fluid is present ; if the hand placed on the abdomen, in 
the right or kit hypochondriac region as the case may be, is suddenly dejircssed, this lluid 
is displaced, and the surface of the enlarged organ can then be felt. This phenomenon of 
■ dipping ' is almost pathognomonic of ascites. 

Percussion. — When the patient lies Hat on his back the fluid gravitates to the posterior 
part of the abdomen, and the air-containing viscera float to the anterior part, so that the 
percussion note is resonant in front and dull in the flanks. As the fluid increases in quantity, 
the line of dullness creeps forward from the flanks and upwards from the pubes, and keeps 
a concave upper border ; in extreme cases the abdomen may be dull all over, particularly in 
children. 

One of the most prominent jihysical signs of ascites is the efl'ect jiroduced on the per- 
cussion note by a change in the posture of the patient. If. after examining him lying on 
the back and finding dullness in the flanks and resonance in the front, he be turned on one 
side, the uppermost flank becomes resonant and the line of dullness on the other side rises 
nearer to the median abdominal line, owing to the fluid gravitating to the most dependent 
part. If only a very small (|uantity of fluid is present, the abdomen may be resonant all 
over when the patient lies on his back ; but if he is ))ercussed in the knee-elbow position, 
the umbilical region may be found to be dull. 

In some cases, especially of tuberculous peritonitis, shortening of the mesentery is apt 
to be associated with the ascites ; the intestines cannot then rise, and the result is didlness 
all over the abdomen, or in very exceptional cases dullness in front with resonance in the 
flanks. Chronic peritonitis may cause the fluid to be loculated, through matting together 
of the intestines. The abdominal distention may then not be uniform, and change of 
])0sture may not alter the character of the ])crcussion note. 

Mensuration. — Tlie abdonun should be measured, fixed points being taken in front 
and behind, e.g., the umbilicus in front and the tip of the third lumbar spine behind. This 
is important in order to watch the effect of treatment. The distance of the umbilicus from 
the ensiform cartilage, pubes, and anterior superior iliac spines should also be noted, yin 
ascites, the navel is nearly always nearer the pubes than the ensiform cartilage, and -equi- 
distant from the two anterior superior iliac spines when the patient lies flat on his back. 

It is always important to examine the abdomen carefully after paracentesis ; the 
cause of the ascites can often be discovered in this way, in the shape of tumours, or enlarge- 
ments of organs, which were previously obscured by the tenseness of the abdominal wall. 

2. DIAGNOSIS. — Ascites has to be distinguished from other conditions which may 
give rise to geiieral abdominal distention, especially from : — Tympanites : Ovarian and 
parovarian ci/fils : Gravid uterus ivitk hi/drops amnii ; Distended bladder ; Distention 
associated 7>.illi obesiti/ : Plianluni tumour ; Large abdominal eysts and solid tumours. 

Tympanites is distinguished from ascites by the following signs : — The outline of 
distended coils of intestine may be visible, and peristaltic movements may be noticed. 
There is no fluid thrill if precautions are taken to prevent a thrill being transmitted by the 
abdominal wall. The abdomen is resonant all over, both in front and in the flanks. 

Ovarian Cyst. — There may be a history of the enlargement of the abdomen having 
been noticed at an early date to be more on one side than the other, and to ha\e arisen from 
the pelvis. The umbilicus may be nearer to the ensiform cartilage than the pubes, and 



ASCITES 45 

nearer to one anterior superior iliac spine than tlie otlier. A fluid thrill may not be obtained 
far back in the flanks, but only in front of the mid-axillary lines. There is usually dullness 
in front, with resonance in the flanks. The outline of the cyst may jiossibly be noticed 
during the respirator^' movements. On measuring the abdomen the greatest circumference 
is usually below the umbilicus ; whereas in ascites it is generally at the umbilicus. A 
vaginal examination may reveal that the uterus is drawn upwards and that its mobility is 
impaired : whereas in ascites it is low down and movable. If ])aracentesis has been per- 
formed, the nature of the ovarian fluid is characteristic, being usually thick, tenacious, 
viscid, and of a brownish or greenish colour ; whereas ascitic fluid is yellowish, limpid, and 
clear. Much dilficulty arises when ovarian cyst and ascites are both present, owing to 
infection of the jjeritoneum by secondary deposits from the ovary. Even without this, 
however, it is by no means alw.ays easy to distinguish between ovarian cyst and ascites 
when the abdominal disteutiiin lias become extreme. 

Gravid Uterus with H.ydrops Amnii. — In this condition it may be possible to 
make out the outline of the enlarged uterus ; the tumour may vary in consistency as the 
uterine wall contracts and relaxes ; on vaginal examination the cervix is soft and patulous 
and the uterus enlarged. There will be other signs of ])regnancy, the characteristic condition 
of the breasts, foetal movements and heart sounds, and the history of amenorrhoea. There 
will be dullness in the front of the abdomen, resonance in the flanks. 

Distended Bladder. — This may reach well above the lunbilicus, most frequently in 
women as tlic residt of a retroverted gravid uterus, or in men over sixty from enlarge- 
ment of the prostate. The most important symptoms are : incontinence of urine from 
over-distention and overflow, and abdominal distention. There is generally a globular 
mass to be palpated in the middle line above the ]>ubes and reaching up to the umbilicus 
or higher : it is dull to jiercussion in front, with resonance in the flanks. The passage of 
a catheter should clear up all doubt. 

General Obesity may cause much abdominal distention. The mesentery, omentum, 
and abdominal wall may be so loaded with fat that it is difficult to make a satisfactory 
examination, and it may be almost impossililc to determine with certainty the presence of 
even a moderate amount of fluid. 

Phantom Tumour, The abdomen may occasionally be so distended in women, espe- 
cially at the time of the climacteric, that ascites, ovarian tumour, or j>regnancy may be 
sinnilated when there is merely a phantom timiour. If an ana-sthetic is administered it 
often disap|)eais, the rigid abdominal wall becomes flaccid, and it can be determined 
whether fluid in the peritoneal cavity or any abdominal tumour is present or not. 

Large Abdominal Cysts may occasionally sinndate ascites, e.g., hy(lrone|ihrosis, pan- 
creatic cvsl, and hydatid <\sl : th(\- do not, however, cause unihirm distrutiou ot the 
abdomen as a rule. They arc most likely to be mislaken for simple chronic ))eritonitis in 
which local collections of fluid have arisen from matting together of the intestines. Hydro- 
nephrosis may be distinguished by its position and by the fact that it may vary in si/.e, a 
decrease being associated with an increase in the amount f)f urine passed. Pancreatic cyst 
may be dilTerenliated by its jxisition in the U)(per part of the abdomen and by its more or 
less circular oulline. If paracentesis abdominis has been peH'ormcd. the character of the 
llni<l and its rerments would ])oint to the nature of the disease. 

'■>. CAUSES. — Having made uj) one's mind that the general alHldininal disttiition is 
due to lluiri in the peritoneal cavit>, on<- must ni \l liiircrcnl iate Ihe canse ol the ascites. 
The following is a classilied list : — 

i. Diseases of the Peritoneum : 

Xon-snppinali\c aenle perilimilis 

■.Simple" chronic peritonitis 

Tul)erenlons peritonitis 

Malignant ])erjtonilis, generally secondary to a priniaiy growth elsewhere 

Hydatid cysts in the peiiloncal ca\ity. 

ii. Obstruction to the main Portal Vein by : — 
Non-snppnral i\c thrombosis 
Ivilargcd portal lymphatic glands : — 

Maliijnanl I 'I'uIk lenluns 

l.ymphadincinialons | l.yrriphal ic lenka-mic 



ASCITES 

Tumours of adjacent organs, such as : — 

Liver I Duodenum 

Pancreas Colon 

Kidney Suprarenal capsule 

Stomach 
Rarities such as aneurysm of the hepatic artery 

iii. Diseases of the Liver : — 

Cirrhosis 

IVrihepatitis, really part of chronic simple j)eritonitis 

Carcinoma j Doubtful causes if the lesions are confined to the liver ; i.e.. 

Sarcoma I it there is ascites, it is probably not due to the carcinoma, 

Sypliilis j etc.. in the liver, but to simultaneous affection either of 

Hydatid disease ) tlie peritoneum or of the portal lymphatic glands 

iv. Obstruction of the Inferior Vena Cava above the Hepatic Veins by : — 
Tliriinil)()sis Mediastinal growth 

Clu'onic niediastinilis 

V. Chronic Failure of the right Heart (' backward pressure ') the result of : — 
Valvular disease : — Adherent pericardiimi 



Mitral stenosis Clironic lung affections, especially : 

Mitral regurgitation Emphysema 

Aortic stenosis or regurgitation with ' Recurrent bron- 



Generally as- 
sociated 



secondary mitral regurgitation i^- chitis 

Rheumatic or syphilitic Fibroid lung- 

Congenital pulmonary stenosis (rarely) Chronic high blood pressure : — 



Red gramdar contracted kidneys 
Pale granular contracted kidneys 
Arteriosclerosis 



Chronic myocardial affections : — 
Fatty degeneration I Fibroid heart 
Fatty infiltration | Primary alcoho- 
Fatty s\iperposition | lie heart 
vi. Bright's Disease. In Bright's disease ascites may be caused in at least four different 
ways. — namely, as the result of : — 

Part of a general dropsy I Secondary to hypertrophy and dilatation 

Acute peritonitis i of the heart, followed by failure of 

Clnonic ])eritonitis < compensation 

vii. Severe Anaeiqias, in wliich the ascites is usually the result of acute, subacute, or 
chronic intercurrent j)eritonitis, as in : — 

Splenomedullary leukaemia I Splenic ana-mia 

Lymphatic leukaemia j Pernicious ana-mia 

Hodgkin"s disease Aplastic ana-mia 

Pseudo-leukicmia infantinii [ Malaria 

f. DIFFERENTIAL DIAGNOSIS. — If a.scites is the only fluid accumulation present in 
the [latient: il'. althougli there is also swelling and oedema of the legs, the ascites is known 
to have apjjeared first : or if the ascites is out of proportion to dropsy elsewhere : it is 
most probably due either to some form of peritonitis, to portal obstruction from thrombosis 
of or pressure on the portal vein, or to cirrhosis of the liver. 

If it is associated with general anasarca, that is to say, with cedema of the legs, body, 
and face, perhaps even of the scalp, and possibly with other serous effusions, the probable 
cause is acute, or acute on chronic, Brighfs disease. 

If swelling and oedema of the legs were noticed first and the ascites followed, heart 
failure from one of the causes in Group V, or obstruction of the inferior vena cava abo\e the 
hepatic veins, would be the most likely cause ; it is important to remember, however, that 
in the slighter cases, or in those of long standing, the patient is often uncertain which swelled 
first, his legs or his abdomen, and his statements on the point may be misleading. 

If jaundice is associated with the ascites, it points to some form of portal obstruction 
as the cause, either cirrhosis of the liver, or, if the jaundice is intense, to some actual pressure 
on the portal vein and common bile ducts, generally due to malignant disease. 

If enlargement of the liver is associated with the ascites this may be due to carcinoma, 



ASCITES 47 

sarcoma, cirrhosis, perihepatitis, s\'pliilis of tlie hver, or to nutmeg change the result of 
backward pressure from ctironic heart or lung disease. 

If the ascites is assf)ciated with multiple abdominal tumours it suggests tulierculous 
or malignant ])crit(initis. or in rarer cases hydatid disease. 

i. Diseases of the Peritoneum. 

Acute yon-suppurativePgjiiloiiilis is an acute inflammation of the peritoneum analogous 
to acute ■ simple " ])jeuris^^^ith serous eflusion. One seldom speaks of ascites, however, 
in connection with ac^te nifective peritonitis such as w^^ti ||j^l D6 pus formation if laparo- 
tomy were not resorted to : and it is dillicult to draw a decW^l^fte between acute peritonitis 
in which the fluid should be called ascites, and other conditions of acute generalized 
peritonitis to which the term would not be applied. There are, however, cases in which 
acute serous effusion due to non-suppurative peritonitis occurs in acute and chronic Bright"s 
disease: or acute tuberculous peritonitis almost simulating general suppurative peritonitis; c 
whilst pneumococcal and gonococcal peritonitis may be acute in onset, and yet take the 
form of an ascitic effusion, recovery occurring without the necessity for laparotomy. It is 
probably a question of the dose of the micro-organism that affects the ])eritoneum, and it is 
by no means impossible that, whereas the perforation of a gastric ulcer, duodenal ulcer, 
dysenteric, typhoid, or tuberculous ulcer of the intestines, or leakage from a pyosalpinx, an 
ai)pendicular abscess, stercoral ulcer of the colon, or a perirectal or prostatic abscess, 
generally gives rise to acute general [jeritonitis which would prove suppurative if it were 
not operated on, the same conditions may in some eases lead to a slighter affection with 
a severe but non-suppurative ascitic effusion ending in s|3ontaneous recovery. AVhether 
laparotomy is indicated or not in any given instance must depend upon the individual 
circumstances of tlie case ; but it is much safer for the jiatient to be operated upon for 
acute non-suppui>tive peritonitis of the type of wliich we are now speaking than for 
general suppurative j)eritonitis to escape operation. 

Sini])le Climm'c Perildiiilis is a chronic inflanunation tliat is not tuberculous or malig- 
n;uit. It may follow siniple acute peritonitis, but its two commonest causes arc : a former 
tuberculous ])critonitis from whieli the tubercles have disajjpeared ; and the chronic inllam- 
mation which results from repeated paracentesis abdominis for any other variety of ascites. 
The latter is important ; it sometimes happens, in a heart case for instance, that both trdema 
of the legs and ascites have been prominent symptoms, paracentesis abdominis being indi- 
cated on account of the cardiac distress ; the tapping of the abdomen may have had to be 
repeated scviTal times, and yet ultimately the cardiac compensation has been restored. 
the patient's general conrlition Incoming (juitc good and the (cdema of the legs disappearing : 
yet in spite of this general improvement, ascites may still persist and re(|uire further tapping 
at intervals. In such a case, whereas at first the ascites was due to backward pressiu'e 
from the failing heart, it ultimately becomes due to chronic ])eritonitis. the result of the 
repeated tappings. It is Tisually associated with perihepatitis, which indeed is only one 
of the local manifestations of <'hr(inie peritonitis. l^Aen when all inllamination has {•cased, 
the great thickening of the peritoneum over the diaphragm, liver, and spleen may liave 
blocked up those pores through which the peritoneal secretions naturally drain away, .so 
that the Ihiid keeps on re-accumulaf iiig, and necessitates re|)eatcd tapping, which in some 
cases has been performed over three hundred times. The peritoneum becomes thickened 
generally, aiul the intestines bfamd down and matted together. There may be local or 
general ahtlominal distention, depending on whether loculi are formed or not liv the adhe- 
sions. On iK'count of the short ciiiTig of the niesentcry and malting together of the inlesliiies 
there may he dullness all over the ahdoruen. so that this form of ascites is particularly liable 
to be mistaken for ovarian cyst or luinour. .Mbuniinuria is fre(|Ucnt on account of interfer- 
ence with the renal circulation, and IIkic may even be a few tube casts : there may or may 
not be actual renal disease, but this should not be diagnosed from the albuminuria unless 
there is also high hlood-prc'ssurc, retinitis, or other eonllrmalory sign. Ahdoniiiial pain is 
generally slight, and although there may be \-omiting or coiislipation. there is usually neither. 
Tiibcrciiloii.s Pcrilonilis.— This is the most eonunon cause of ascites In eliildrcn. There 
are several varieties, of which the following may be distinguished : — 

1. The acute a.scltie form, whieli may siimilate acute general peritonitis due to perfora- 
tion of a viscus (see above). 

2. The peritoneum may be studded all over with miliary tubercles without any caseous- 



48 ASCITES 

masses. The ]ihysical signs are those of ascites without any abcloniinal tumour, and it is 
not diflicult to mistake it wlien it occurs in an adult for cirrliosis of the li\er or for malignant 
peritonitis, especially that form wliich is secondary to ovarian tumour. In a child, the 
occurrence of ascites witliout u'dema of the legs at once suggests tuberculous peritonitis ; 
in an older person tuberculous peritonitis is much less common. 

3. The omentum may be contracted and thickened from infiltration with caseous or 
fibro-caseoiis material, and a hard abdominal tumour simulating an enlarged liver may be 
felt. It may be distinguished, liowever. by the resonant percussion note between it and the 
costal margin, and the liver edge may be palpable above and distinct from the omental 
mass which simulates it. Ascites in cases of this kind is generally less in amount than 
in the miliary tuberculous form. 

■i. The intestines may be matted together and the adhesions thickened and infiltrated 
with tuberculous deposits, so that the peritoneal cavity may be divided into several loculi 
of fluid, tfie abdominal distention being not uniform, and paracentesis only removing part 
of the ascites. 

5. The mesentery may be thickened and contracted, and tlie intestines bound down 
to the posterior parts of the abdominal cavity, so that if there is ascites there will either be 
dullness all over the abdomen, or dullness in front with resonance in the flanks, suggesting 
ovarian cyst rather than tubercidous peritonitis. After paracentesis, a more or less defined 
irregular deeply situated tumour may often be felt. 

6. \Vhen the caseation affects the mesenteric glands in particular, multiple irregular 
tumours are felt, sometimes but not always associated with ascites. 

7. Occasionally local thickenings in the abdominal wall are to be felt as the result of 
subperitoneal inflammatory deposits, a condition which may often be mistaken for rigid 
contraction of the recti muscles or for disease of the parietcs rather than of the peritoneum ; 
if. however, there is ascites at the same time, tuberculous peritonitis would be very 
proljable, particularly in a child. 

It will naturally depend upon the acuteness of the tuberculous process whether there 
will be pyrexia or not, and whether there will be abdominal pain and tenderness. In the 
caseous varieties, whether of the glands, omentum, mesentery, or abdominal wall, pain and 
tenderness are the rule, and the temperature generally rises to 101° F. to 104° V. each 
evening. It is not at all unconunon in such cases for redness and oedema to develop roimd 
the umbilicus, and for a purulent discharge to occur from the latter, or for a fiecal fistula to 
develop. The commonest cause for spontaneous fsecal fistula of the umbilicus is tuberculous 
]jeritonitis. When the active tuberculous process has become quiescent there may still 
be ascites, though the temiierature is subnormal. AVhen paracentesis is performed, it is 
advisable to inject some of the fluid into a guinea-pig, to see if the latter develops general 
tuberculosis. The nature of the case may sometimes be suggested by the presence of tuber- 
culous lesions elsewhere in the patient's body ; for instance, in the spine, kidney, a joint 
such as the hip or knee, glands in the neck, or lupus, though very often tuberculous peritonitis 
is the only objective lesion. 

Ascilic Fluids. — It lias liocn stated tliat chemical analyses of ascitic lluid often afford material 
assistance in arri\ ini; at a diaL;iii'--is oT its eau>e : lait in |ji'actice only the broadest conclusions can 
be drawn. The liiulni I lie sihiiIh- ijiasily, llir laii^er the jicrcentage of albumin, and the greater 
the tendency to spuMlaiu mis c cpai;iilali"ii. tin- nimi- dilinitely can one conclude that the condition 
is an inflammatory exudate — e.g., specilic gravity l,0'j."i. luiiity ])aits per thousand of albumin, 
with a spontaneous coagulation. The lower the spn illc i;iavity, the smaller the percentage of 
albumin and the more definite the absence of spontaiu oiis ((laiiulatioii tlic more likely is the condi- 
tion to be a non-innamniatory transudate — e.g., speeilic gravity 1,005, five parts per thousand of 
albumin, and no coagulaf inn. There are, however, many intermediate cases in which chemical 
investigation of tlie lliiid leaves one in doubt as to wliether the condition is inflammatory or not. 

It lias also been stated that diflenntial analyses of the proteids are lieljjful, notably as to 
wliether there is more globulin or more alliiiiuiii lucsent : but it is doubtful whetlier this really is so. 

iMiei'oscopical examinations are ninre \ahialjle than chemical ; the centrifugalized deposit 
sliould be examined under the lii;;li pci«(r ; it may exliibit many leucoc\^es in intlaminatory con- 
ditions, polymorphonuclear cells inrdoiniiiating in acute conditions, small lymphocytes in siiljaiiite 
or chronic affections such as tulierciildus ]ieritonitis ; peritoneal cells in cases of inllanuiiation ; 
and ncra'.idnally the diagnosis is elinelicd by finding actual fragments of new growtli or hydatid 
liouUli Is ( /■(!'. IS). 'I'lic (li |M)sits may also be stained for bacteria, and sometimes tubeicle bacilli, 
strc]itci(iH I 1, sl:i|.h\ l.jcdcci, ^diincncci, or pneumoeocci may he found. When investigating ascitic 
fluid liacUiiulciijiealiy, lui\ve\er, it is jjrobalily better to resort to cultural or inoculation methods 
than to rely solely ujion liliiis prepared from the deposit. 



ASCITES 



49 




Cancerous Peritonitis usually occurs in patients over forty, and the growth is practically 
always secontiary. Primary carcinoma of the peritoneum is very rare, and it is usually 
colloid aufl not associated with ascites. In secondary cases the omentum may be thickened 
and infiltrated, the umbilicus fixed, the urachus palpably infiltrated, and nodules and masses 
may develo)) all over the peritoneiun. Rapid emaciation and cachexia are the rule. .\ 
large quantity of fluid may be present, and if it is blood-stained at the first tapijing tjiis 
is very suggestive of malignant disease. 
.Ascites may be the first and only evidence 
of growth, and it may be mistaken for that 
of tuberculous peritonitis or cirrhosis of the 
liver, especially when the abdominal disten- 
tion is so marked that no nodules can be 
felt. Evidence of a primary growi^h should 
always be looked for with care, especially 
in connection with the stomach, pancreas, 
colon, rectum, or ovaries. Rectal examina- 
tion should never be omitted, and if need 
be the sigmoidoscope may be used. It 
should not be forgotten that usefid indica- 
tion of intra-abdominal malignant disease 
is sometimes afforded by enlargement of 
the left supra-cla\icular lymphatic glands 
by secondary deposits {Fig. 17). 

There is one variety of secondary 
malignant peritonitis which merits special 
mention — namely, that which may result 
from a proliferating papillomatous ovarian 
cyst. The malignancy of the latter is 
sometimes relative, so that although there 
may be thousands of ])a))illoma deposits on 
the peritoneum, causing ascites that may 
need tapping scores of times at short in- 
tervals, there may be no other secondary 
deijosits aiiyv>lurc. The diagnosis may be 
made as I lie nsult ol careful vaginal examination, 
nanl ])apillomata in the ascitic fluid, or ])erliaps I 
■ simple ' peritonitis until the abdomen is opened. 

Ili/iliitiil ( 'lists in the peritoneal cavity may Ix- primarx, hut more often they are 
seeondarx lo lix.iatid disease of the liver. The malady is rare in this country, though 
comiuoTK T ill Australasia and elsewhere. The patient is generally an adult and th<' diagnosis 
is often obvious, though sometimes it may be very obscure. There 
may be a large globular tumour in the lixer. rarely giving the 
typical hydatid thrill : lliere ma\ he I^osinoimtu.i.v (p. 219). and 
an investigation ol I he lilooil scniiii in special laboratories may 
show the specilie hydatid scniiii reaclioii. In some eases in whieii 
there are hydatid cysts associated with ascites it is possible to 
make the diagnosis by rectal examination ; one has felt globular 
bodies about tlie size of grapes in front of the anterior rectal wall, 
and when these have been pressed upon to investigate them more 
fully, they have slipped away frotn imder one's linger through 
being pushed up into the ascitic fluid ; after waiting a moment the 
back into Douglas's pouch. .Similar mobility of spherical masses 



Fiff. 17.— Knlarsremeiit of the left supraclavicular glands 
ill a ca.se of abdominal malignant disease (carcinoma of the 
si!,'inoid colon). 



ir bv findin 



fragments of the iiialig- 
l)e regarded as ehrciiiic 



I'iij. IS.— Eel 



1 



(P^ 



linger has icil thin 
in the asej|l<' fluid iii:iy ix 
diagnosis depends U|ioii I he 
centesis or by la|)aidlomy. 
of liooklcis dors nol rxellldc 
ease nol |ndduciiii; hooklrls 
Cliilloiis .i.scilis is nol ill 



noted 



where lor iristan<-e. in an iliac fossa. The ultimate 

ileleelion of hooklels (/•'/i,'. IS) in I he lliiid obtained l)y paia- 

II is iiii|iorhiiil to hear In iiiiiid. h 

hxdalid (lisr;isc, llie cysts sometimes 



ilscir 



specilie iiialaily. tor lln 



we\-er. 


that 


the absence 


icing si 


erile 


. and in llial 


ire Ihaii 


one 


eonililion in 
1- 



50 



ASCITES 



which the ascitic fluid may ajjjjear hke milk. Tliis may result from obstruction to the 
main abdominal lymphatics, particularly the receptaculum chyli and thoracic duct ; or 
from their rupture after injury to tlie abdomen ; more often the condition is associated in 
this coimtry, in some way which is not fully understood, with the ]5eritonitis of chronic 
T}ri«lil'.s- Discaxc, or of leiihceniia. The best known tropical cause for chylous ascites is 
Filfirid saiigiiiiiis hotninis with cle])hantiasis. In rare cases the secondary deposits of 
nuilioiiant disease may be such as to obstruct the thoracic duct, and so produce' the 
chylous condition of the ascitic fluid. Chyluria may or may not occur at the same time. 

There are two types of chylous ascites, one in which actual chyle accumulates in 
the peritoneal cavity as the result of direct leakage from the thoracic duct or receptaculum — 
true chylous ascites ; the other in which the condition is in the main one of ascites, but the 
fluid becomes milky-looking from little-understood chemical changes taking place in it, 
particularly in the proteids. This is termed chyliform ascites, or pseudochylous ascites. 
There is much more real fat in the former condition than in the latter : but chyliform ascites 
is commoner than true chylous ascites. The diagnosis between the two is afforded by 
chemical and microscopical analyses of the fluid obtained by tapping, the chief points of 
distinction being as follows : — 



Chylous Ascites. 

1 . The fluid tends to accumulate very 
rapidly, and in consei|Ucnec larjic vohuucs arc 
rcinoved at ])araccntesis. 

2. (icneraily ycUowish-wliite in colour and 
less perfectly emulsified. 

3. IJegree of o])alescenoe nifnc or less con- 
stant at successive tappings. 

4. Possesses an odour corresponding to the 
odour of the food ingested. 

a. Microscopically the fluid contains fine tat 
"lobules, but vcrv few celhdar elements. 



6. General 
n standin". 



distinct creaniv layer 



7. S])erilic i;ravity i;inirally exceeds 1012. 
S. Drpivssiim i.t irc-i/.in;; piiint about 0-51° C. 
and approximating that l<pr eliyle. 

9. Total solids vary considerably, hut usually 
exceed 4 per cent. 

10. The total protein content f;onerally ex- 
ceeds 3 grams ])er cent, and of this the strum- 
albumin is the largest fraction, gloliulin occurring 
only in traces. 

11. JIueinoid sidjstanees absent. 

12. The fat content is generally hiyh, vaiyiny 
liom 0-4 to 4 per cent. The fat corresponds 
in all its ])roperties to the fat contained in food. 

I.'!. Of the lipius cliolestcrol is invariably 
f(iiui(l. and lecithin only ociurs in traces. 

14. Xo cvideiue of the presence of a lipin- 
ulohulin eondiinatiim. 



15. The salts and the organic substances 
present api>roximate to the values found for 
ehvle obtained from the thoracic duct. 



Cliijtiform Ascites. 

1. Collects more slowly, the volume of the 
fluid varying with the exciting pathological 
condition. 

2. In colour a pine milky-white solution in 
the form of an almost perfect enudsion. 

3. The opalescence generally increases or 
diminishes at successive tappings. 

4. Odourless. 

5. Microscopically the qiumtity of free fat 
is variable ; often numerous Hue, highly refrac- 
tile granules are present, and these do not give 
the reactions for fat. Cellular elements may 
be numerous and often contain fat ; sometimes 
very scanty. 

(). \ cream may or may not form, but does 
not affect the o])aIeseenee ; a sediment fre- 
quently settles out. 

v. Specific gravity less than 1012. 

8. Dei)ression of freezing point ranges from 
0'36° to 0'61°, and thus corresponds to the 
tifiures for blood scrum. 

)l. Tcital solids rarely exceed 2 per cent. 

10. The ])rotein constituents vary between 
1 and 3 grams per cent, and of these the 
serum-globulin occurs in ap|)reeiable quantities. 

11. .Mueiiioid substances present. 

12. The fat content is generally low, and it 
may be present in traces only : in its melting and 
chemical composition it jjrovcs to be patho- 
logical fat. 

13. The most characteristic lipin is lecithin, 
though cholesterol is occasionally present. 

14. The lecithin is mainly combined with the 
iilobiilin, and when present is the cause of the 
opalescence of the fluid. Such fluids resist 
putrefaction. 

!.■). The salts and organic materials correspond 
closely to those of lymph and serous fluids. 



ii. Obstruction to the Main Portal Vein. — This is most commonly due to enlargcmctii 
I J llic jKirtiil lyniphiilic Shiiiils by secondary deposits of malignant disease ; it is common for 
the main bile-ducts to be ob.structed at the same time, so that an increasing depth of jaundice 
accompanies the ascites. When there are masses of secondarv' growth in the liver associated 
with jaiuidicc, or ascites, or both, it is seldom that the hepatic masses are themselves respon- 



ASCITES 51 

sible for tlie syniptonis, these being more often due to tlie associated deposits in the i)ort:il 
lymphatic glands. The diagnosis is made on discovering a primary growth, more often a 
carcinoma tlian a sarcoma. It is much rarer for tlie lympliatic glandular enlargement to be 
lymphadenomatous. tuberculous, or due to lymphatic leukaemia. If ascites were a promi- 
nent symptom in any of these conditions, it would be regarded as consequent on affection 
of the peritoneum rather than on obstruction to the portal vein, unless there were deepen- 
ing jaundice at the same time. In the latter ease malignant disease would be simulated. 
General enlargement of the lymphatic glands in tlie axilla", groins, and neck, with or without 
evidence of enlargement of those in the thorax or abdomen, together with enlargement of 
the spleen, would suggest either lymphadenoma or lymj)hatic leuk;emia ; the absence of 
positive blood changes would render the former more likely, for in lymphatic leukEemia there 
is more or less considerable leucocj-tosis with a great relative increase in the small lympho- 
cytes up to 90 per cent or more (p. 25). Only in very rare cases do tuberculous portal 
glands cause ascites, and when they do the diagnosis must be one of guess-work only, unless 
in association with definite tuberculous jieritonitis there were jaundice suggesting obstruction 
to the common bile-duct and to the portal vein at the same time. 

Thrombosis of the porlti! rein may be su])purative. in which case there is no ascites, but 
a pjTexial condition with rigors and possibly jaundice, diagnosed as a rule only when there 
has been sonic delinite inflammatory focus in the portal area, such as appendicitis, which 
miglit lead to infection of the portal vein. Primary thrombosis of the portal vein is rare, 
and its diagnosis can seldom be more than guessed at. It leads to marked ascites, possibly 
with simultaneous increase in any tendency there may be to piles, and without evidence of 
tuberculous or malignant disease of the ijcritoncuni or cirrhosis of the liver. It is by a 
process of exclusion that the diagnosis of portal vein thrombosis might be arrived at. 
especially if the ascitic fluid withdrawn by paracentesis, when examined chemically, were 
found to contain a relatively very high proportion of coagulable jsroteids without any par- 
ticular tendency to spontaneous coagirlation. and without those polymorphonuclear cells 
or lymphocytes that would be found if the high i)ercentage of proteid were due to the 
ascites being iiiHaiumatory. 

'riinioiiis (if iitljdci'rit orgaii.s seldom obstruct the portal vein enough to cause ascites 
willioul presenting other symptoms which suggest the diagnosis. Sometimes, however, 
unless the tumour can be felt, great dilliculty may be experienced in determining the nature 
ol the ease, t arcinoma of the pancreas may be accompanied by glycosiu'ia and the passage 
of fatly stools, io/etlier with deepening jauTidice, progressive enlargement of the gall-l)ladder, 
and a positive ('a\i.\iii)(;!-.'s I' \n( lii-.ATic Hi'.ac IION (p, 100). On account of the relation of 
the tumour to the aorta, marked transmitted pulsation may be felt in it, and by inflating 
the stomach it may be demonstrated tliat the tumour lies posterior to the latter. Kenal 
tumours may be dilliciilt to distinguish from enlargement of the liver when they are big ; 
but they are generally a.ssoeiated with Albtminuiua (p. 1). II.KMArrniA (p. "275), or 
l'^ I ui.v (p. 57 1). Carcinoma of the stomach, duodemun. colon, or suprarenal capsule 
would be suggested by tlie ])osition of the mass, or by the gastric or inteslinal symptoms ; 
if there were ascites aeeomjjanving them, it would generally be due not to the primary 
tumour, b\it to secondary deposits cither in the peritoneum or in the portal lymphatic glands, 
.Inriirysm of the liepiilic iirliri/ is a pathological curiosity, though in recorded cases it 
has produced ascites and jaundice. The conunonest cause of aneurysm of the hepatic artery 
is fungatiiiir endocarditis with embolism. 

iii. Diseases of the Liver, Cirrhosin of llif l.ivrr. Wlicn asciirs is ihic lo ihis the 
<lia.:nosis is sometimes easy oTi accoiinl of the liisl(]ry of chniiiie aiciiholism, and possibly 
of ioriner luematemcsis, mclaria (ir jaijiKlicc. Tlicie ma\ also he acne rosacea and 
lelangicetases on the cheeks, or ex en a hot lle-iiose. a furred and tremulous tongue, a 
history of morning sickness, cramps in I he legs at nighl, nausea, loss of appetite' especially 
lor breakfast, epistaxis, perhaps the presence of distended veins roimd the umbilicus, 
liicmorrlioids, enlargement of the M\(r. the surface of which is hard and rough and the edge 
irniiular anil perhaps beaded, enlargemenl of the spleen, icteric tinge of the eonjuiicl i\ a\ 
and a peculiarly sallow, slightly pigmented laeies, which is almost eliaraelerislie in the later 
.stages of the malady. ( irrhosis is a slowly progressive disease sometimes extending over 
twenty years or mure, producing a large, smooth, unilobular cirrhotic liver with jaundi<'c 
and a l( ihUiicv to liMinalcmesis in its earlier sialics ; but later a small li\<r In which, in 



52 ASCITES 

addition to the unilobular fibrous tissue, there has developed a much coarser multilobular 
meshwork which, by progressive contraetion. has led to the previously large, smooth organ 
becoming smaller, rougher, and harder, initil it may sometimes be so small as to be no longer 
palpable. Only in the very last stage does it produce ascites. People have been known to 
be total abstainers for as long as eighteen years or more after the first symptoms of cirrhosis 
have developed, and yet to die with a granular, contracted. " hob-nail " liver and ascites. 

Perihepatitis. — A case of cirrhosis of the liver seldom survives long after it has first 
become necessary to tap the abdomen, and when paracentesis abdominis has to be performed 
more than once or twice in a case supposed to be cirrhosis, this points to the diagnosis being 
wrong, the case being one, not of cirrhosis, but of perihepatitis. This is not always so, how- 
ever, for it happens sometimes that even when the ascites was originally due to cirrhosis, 
the repeated tapping produces perihepatitis, the greatly thickened capsule of the liver 
being the result of multiple tappings for what was at first cirrhotic ascites. It is exceedingly 
difficult to be certain of the diagnosis of simple perihe])atitis ; the condition is really only part 
of a chronic jjeritonitis. The capsule of the liver becomes much thickened, and it contracts 
and distorts the organ, and rounds the edge, or else turns it \\\> or under, in a way which is 
characteristic. It is only if this eurlcd-under or turned-up edge can be detected that the 
diagnosis of perihepatitis can be made with certainty. Syphilis is possibly the cause of the 
malady in some cases. 

Ascites associated with carcinoma or sarcoma of the liver is usually accomjianied by 
intense jaimdice. and there is always doubt as to whether these symptoms are not due 
rather to coincident affection of the portal lymphatic glands than to the deposits in the liver 
itself. The latter becomes much enlarged, \ ery hard, the edge often coming well below the 
uml)ilicus. Probably the largest livers that occur are due to secondaiy carcinoma or sar- 
coma. They may reach a weight of 22 lb. or more. Besides being very hard, the liver may 
be tender, and umbilicated nodules may be felt on its surface. Primary growth of the liver 
is exceedingly rare, and though it leads to progressive and deejjening jaimdice, it does not 
often produce ascites. Secondary growth is so much more common, that it is important to 
look for the primary growth elsewhere with great care before primary growth in the liver is 
diagnosed. Retinal and rectal examination should not be omitted ; and Cammidge's pan- 
creatic reaction (p. 100) should be tested, in case the primary growth be in the pancreas. 

Syphilis may produce local peritonitis over a gimima ; it may also lead to general 
chronic peritonitis and thus to ascites. The diagnosis is made upon the history, upon the 
signs of syphilis elsewhere, and upon Wassermann's serum reaction. 

Hydatid disease of the lix'cr seldom of itself causes ascites, though it may be associated 
with coincident affection of the peritoneum with ascites (p. 49). 

We may now pass on to consider those cases in whicli. if the history is correct, there has 
been swelling of the legs l)ef'ore. or at any rate not later than, swelling of the abdomen : and 
if one Icillows the classilication as given on pages f.") and +(i. one CDnies next to : — 

iv. Obstruction of the Inferior Vena Cava above the Hepatic Veins. — This is rare, 
and will seldom be diagnosed imless there is either (1) clear evidence of extension of throm- 
bosis to the inferior vena cava from a previous thrombus in one leg, associated with exten- 
sion of oedema up the back, followed by albuminuria and perhaps ha-maturia when the 
renal veins are involved, and then by ascites, together with varicose distentif)n of the 
abdominal veins and re\ersal of the blood-stream in them • or (2) a history or the physical 
signs of chronic mediaslinitis. which generally results from recurrent attacks of pleurisy 
and pericarditis, esijeeially rheumatic, or of iiitratiioracic neiv groicth. which is distinguished 
from chronic mediastinitis by the shorter history and by the .r-ray appearances. {Fig. 42, 
p. 105.) (See Veins. Varicose TnoR.\cic, p. 750; and Veins. Varicose Abdominal, p. 748.) 

V. Chronic Failure of the Right Side of the Heart (Backward Pressure). — Ascites 
as the result of backward pressure in chronic heart and lung disease is nearly always preceded 
by swelling and (edema of the legs. Careful examination ol' the heart and lungs, a history 
of acute rheumatism, or of recurrent winter cough, or an abundant and oftensi\e periodic 
expectoration, may suggest valvular disease of the heart, chronic bronchitis and emphysema, 
or fibroid lung with or without bronchiectasis, to account for the ascites. Nutmeg liver 
also results in these cases, the enlargement varying with the degree of heart failure, the 
surface of the organ being smooth, sometimes pulsating synchronously with the heart. 



ASCITES 53 

tender, with a well-defined edge which may reach below the level of the innbilicus in the 
right nipple line. The urine is apt to contain albumin, and when the heart failure has 
reached an advanced degree it may be exceedingly difficult to say whether it is due to primary 
valvular disease, primary lung disease, jirimary kidney disease, primary arterial disease, 
oi to primary affection of the muscle of the heart. The importance of casts in the urine 
in the differential diagnosis has been referred to under Albiminuria (p. 6), where the 
significance of the blood-pressure, of retinal changes, and so forth, are also discussed. 

The valvular heart lesion most ajit to be mis-diagnosed in connection with ascites is 
mili/il stenosis ; for by the time the heart failure has reached a sufficient degree to cause 
ascites, characteristic bruits, especially the presystolic, become no longer audible in many 
cases. The heart beats very rapidly and irregularly, no bruits may be audible at all. Mitral 
stenosis may still be suggested by the characteristic appearance of the face, with its yellowisli 
|)Mlior of the forehead, and around the nose and mouth, with bright or dark red coloration 
of the lips and over the malar bones and upper portions of the cheeks ; or by the history of 
acute rheumatism or chorea, though absence of such a history by no means excludes valvular 
heart disease. It may, however, be im]M)ssible to say whether there is mitral stenosis or 
not mitil the patient has been kept in bed, given digitalis, and watched for a week or more, 
until there is some degree of recovery of the cardiac compensation ; by whieli time the 
characteristic bruits of mitral stenosis very often return with the increasing force of the 
lieart"s beat. 

Some of tlie luirdest ol luart-laiiure cases to diagnose with certainty are those due to 
cliioiiic iijjvctioiis of the iiijpciiiiUnm or to adhiicnt pericaidiiiiti. In each case the diagnosis 
is arrived at mainly by a process of exclusion. Chronic myocardial degeneration seldom 
occurs in young people, or at any rate it is much commoner in middle life and later. The 
symptoms are those which are connnon in all varieties of chronic heart failure (p. 418), what- 
e\er the cause of the latter. There may or may not be the systolic bruit of mitral regurgita- 
tion, or a7i aortic systolic bruit due to atheroma of the aortic valves, but upon the whole 
the physical signs do not suggest vahular disiase : the urinary ihanges and the absence of 
casts do not suggest nephritis or granular kidney : the blood-pressure may not suggest 
arteriosclerosis : the lung signs do not suggest bronchitis and emphysema, or fibroid lung : 
so that some myocardial affection is all that is left to diagnose. If there is a history of tlie 
drinking of much alcohol, particularly beer. iiriiiKiiii (ilcniiiilir heart may be susiiected, though 
this is less eonuuon in Kuglaud than in (iermany. Fall// superpiisition would he suggested 
if there was general ot)esity with shortness of breath on orditiarv exertion ; whilst overload- 
ing of the surlaee of the heart seldom occurs without some />(//)/ iiililtriilioii at the same time. 
Fatlij (leoeiiernlioii is more likely after a long febrile illness, or chronic (joisoning by phos- 
phorus, arsenic, or lead, or by the hy])olhctical toxins of severe anu-mias, such as pernicious 
or aplastic ana-mia. Fibroid lie/irl is very dillieidt to distinguish from fatty heart, but it is 
the more likely in a syphilitic patient, particularly if tlic palieiil is not obese and if there 
Is syphilitic aortic reyuruilatioii or angina pectoris. 

-lilliereiil perirardiinii is not in itself an explicit term, for tin re are three dill'ereiit <(indi- 
lions which come under the one heading : there luiiy be (1) .\dhesions between the parietal 
ami visceral layers of the perieardimn ; (2) Adhesions between the iiarietal |)erieardium 
and tlie structures around it, particularly the i)leura', diaphragm, and chest wall ; or (3) 
.Vdhesions bolli of the parietal to the visceral layer of |)ericardiiun and of the parietal layer 
to the structures outside it really a form of chronic niediastinitis. It is clear that the 
physical signs will difler aeeonliui; to which of these three things has hap|)eMed. That 
whic'li ought to be implied strictly 1>\ llie term adherent pericardium is adhesion of the 
|)arlctal to the \ise( lal layer, without aii\ oIIkt aclhcsioiis whatever, and of this condition 
there are no positive physical signs at all. \u\r need lliei<' be any symptoms. The diagnosis 
is generally made by "iiess-work. the palieiil being known to ha\c had pericarditis, or being 
suspected of having had it because of having sulfered from aeule rlieunialism willi severe 
complications, and the heart now being round iinieli larger than it ought to he in proportion 
li' the apparent valvular disease as indiealeil li\ I lie bruits. It is common, however, for the 
parietal and visceral layers of |)ericardiuMi lo he universally adherent without the hear! 
being big. iiiul without there being any ill erieets at all. the condition being met with posl- 
niorteni in patients who die of something cpiite dilTcrent. It is otdy when the parietal layer 
has become .•KlhcrenI lo the xisecral la\cr when the heart was alreads' dilated at the lime nf 



54 ASCITES 

the |)eiiciirditis that symptoms subsefjuently accrue, the result riither of the inability of the 
already big heart to maintain siillicient hypertrophy than of any intrinsic interference 
with its action by the adJierent pericardium itself. It quite often hap])ens. indeed, that 
when there has been rheumatic myocardial affection without ])cricarditis. the big heart that 
results is out of all proportion to the valvular disease, and yet in the post-mortem room no 
abnormality of the pericardiinn is found. 

The following points in connection with heart disease in children are as true as most 
aphorisms : mitral stenosis is almost unknown before puberty, whatever the bruits that 
suggest it ; heart disease never proves fatal before puberty unless as the result either of the 
severity of the acute inflammation of valves, muscle, or pericardium, or else from adherent 
pericardium. Fatal mechanical failure of the heart before jjuberty in a patient who presents 
no symptoms of rheumatic reinfection points to adherent pericardiimi. 

Adhesions between the parietal pericardium and the structures outside it, without any 
adhesion between the parietal and visceral layers within the pericardium, are exceedingly 
common, generally resulting from former ])leurisy. The former inflammation must have 
extended outside both the pericardium and the pleune. so that it was really a mediastinitis ; 
but clinically the condition is seldom spoken of as mediastinitis. because it is of very little 
importance, and in itself produces no symptoms ; the physical sign which might suggest it 
is deficiency in the movement of the position of the cardiac impulse to the left or to the right 
as the patient rolls from one side to the other. 

The third variety of adherent pericardium, namely that in which there are adhesions 
between the parietal and visceral layers and between the jiarietal layer and the chest wall, 
pleurse, and other structures outside it, is really a combined condition of adherent pericar- 
dium and mediastinal adhesions which, when an extreme degree is reached, becomes what 
is known as chronic mediastinitis. Here again, it is possible for neither symptoms nor 
physical signs to present themselves, the condition being found unexpectedly in the post- 
mortem room. It is this condition which is generally diagnosed under the name of adherent 
pericardimn. There will be a history of former pericarditis, pleurisy, or both, probably 
rheumatic. The heart will be large out of all proportion to any valvular disease that is 
present, without there being other ob\ious cause for its hypertrophy and dilatation, such as 
nephritis, arteriosclerosis, hard work, alcoholism, fatty or fibroid heart, or chronic lung 
disease. If the ])arietal |)ericar(liiuu is adherent both to the pleura" and to the diaphragm — 
particularly the latter — there will very likely be retraction of the lower left ribs posteriorly, 
synchronous with the heart-beat ; it is this physical sign — systolic retraction of the lower 
left ribs — which is generally regarded as pathognomonic of adherent pericardium ; it is 
really evidence, of course, of adhesions outside rather than within the pericardimn. The 
sign needs to be looked for with some care ; the observer watching the posterior profile 
of the left chest from the patienfs left side, small movements obviously due to cardiac and 
not 7-esi)iratory action are to be seen in the ninth or tenth intercostal space in the line of 
the angle of the scapula, or just outside this : irregularity in the heart's action often render- 
ing these visible only now and then — perhaps only when a strong heart-beat happens to 
coincide with the most favourable phase of respiration. The sign, however, is far from 
uncommon. Another physical sign which is regarded by some as indicative of general 
pericardial adhesions, is an ingoing imi)ulsc in the third or fourth intercostal .space half-way 
between the left nipple and the left liordcr of the sternum, synchronous with an outgoing 
impulse nearer the apex, giving an oscillating or see-saw appearance to the precordial 
region — some of the intercostal spaces moving inwards at the same time as others move 
out with the heart-beat. As a matter of fact, the probable explanation of the ingoing 
mo\ement nearer the stern.mi when the part of the heart which is nearer the apex causes 
the ordinary outgoing impulse, is the visible withdrawal of the hypertropliied right ventricle 
as it contracts. This see-saw appearance in the precordial region is indicative therefore 
of great hypertrophy of the right ventricle ; it does not indicate what is the cause of this 
hypei-trophy, though amongst its causes would be adherent pericardium. A similar 
appearance is often seen in cases of extreme mitral stenosis of long standing, even when 
there is no adherent ])ericardium. 

Bright's Disease may produce ascites in more ways than one : the effusion may for 
instance. sim])ly be part of a general anasarca, the accumulation of the ascitic fluid in the 
peritoneal cavity corresponding precisely with its accunmlatiou in the sTibcutaneous tissues ; 



ATAXY 55 

or the Bright's disease may lead to aeute or chronic peritonitis of the types described above ; 
or. especially in chronic cases associated with pale or red granular contracted kidneys, there 
may be failure of the dilated and hypertrophied heart, with ascites, which may be very 
difficult to distinguish from that of primary heart disease ; especially as the greater part of 
the associated albuminuria is now the result of the heart failure rather than of the renal 
sclerosis : and easts may seem unduly few in proportion to the albinnin. If the blood- 
pressure is \ery high the diagnosis is more likely to be arteriosclerosis or granular kidney 
than primary heart-failure, though, curiously enough, the blood-pressure is generally above 
normal in heart-failure from any cause, even when the pulse is as irregular and feeble as it 
often is in the late stages of mitral stenosis. This terminal rise of blood-pressure in heart 
cases pr(ibal)ly results from the ]5artial asphyxia. 

Severe Aneemias often cause ascites, but they do not give rise to much difficulty in 
diagnosis, because the sub-acute or chronic peritonitis which is the cause of the ascitic 
exudate in these eases arises, as a rule, comparatively late in the disease, after the diagnosis 
has been made on other grounds, by blood-counts and otherwise. (See An.emia. p. 20 : 
.Spr.KEX. Enlargement of, p. 028 : Lv.mph,\tic Gland Enlargement, p. 376.) One need 
not do more here than refer to the huge enlargement of the spleen without lymphatic glan- 
dular enlargement, and the great leucocytosis with a large jjortion of myelocytes, in spleiio- 
midiitlari) leukcemia : the considerable leucocytosis. the enlargement of the lymphatic 
glands and probably of the spleen, and the great relative increase of the small lymphoc_\-tes, 
in lymphalic leukcemia ; the enlargement of the lymphatic glands and of the spleen, and the 
absence of any positive blood changes, beyond ana>mia of the chlorotic type without leuco- 
cytosis. in Ilorlskin'fi disease : the enlargement of the spleen, the absence of lymphatic 
glandular enlargement, and the occurrence of a progressive and ultimately severe an:rmia. 
of the simple chlorotic type without leucocytosis, but with an occasional myelocyte and 
basophilc corpuscle, in splenic ana'inia (which often, as the course of the disease goes on. 
turns out to be cirrhosis of the liver) ; the profound anaemia and the high colour-index 
without leucocytosis. in pernieious anmmia ; the severe aniemia suggestive of j)ernieious 
aniemia. but with a persistently low colour-index, in aplastic anwmia ; and the s])lcnic 
enlargement with profound chlorotic ana-mia without leucocytosis, in pseudo-lciika'mia 
irfaiilum. Ilerh'il French. 

ATAXY is tlic term used to describe voluntary movements which are imperfectly 
controlled or co-(>nlinate<l. It is displayed in its simplest form by infants under the age 
of one year. In palliologieal slates, it is often a sym|)tom of great diagnostic importance; 
but before its value as a localizing sign of disease can be utilized, it is necessary to 
ai)preciate broadly the physiological mechanism by which co-ordination is brought about, 
and the possible situations where a lesion is able to disturb the smooth working of that 
mechanism. For the proper co-ordination of xdlunlary m()\<iiient. impulses from the 
muscles, tendons, joints, and skin of the part which is moved nnisl naeli the brain. These 
impulses are of two kinds : 

1. .Sensory alTerciil impulses wliicli ;iic ciinicl l(. tin' nnhniiii li\ wii\ of tlic p(ii|ilii'i:il iiiTses, 
llic |)Ost(-ri()r eohunns of the coM, the lilkt, :inrl liii;illy IVotu the l):is:il ■iViu;;!!:! [« tin- imlex iu the 

neiyhbourhoDil ot' the luotov ;u<a. 'I'licse iriipiilscs crnss Ir rie side nf Ijic IiihIv tn llic opposite 

lieniispheie, the erossiu;; taUiiiL; place In the medulla. 

2. Non-.^eiis(>ry allerenl iiupulses, so-cmHciI t)ee:iusc llicy ucxcr reacli (■(lusciiiusiiess, pa.ss 
from tlie pciiplicnil sinietincs coiicerued in niovenicul. hv wav of the pciiplieial nerves and the 
iiseendiiiL' ccrilu'lhir lra<-ts of the eoid. to the ccrchilliifii, and I'liincipMlly to the eerelellar lolic (if 
the same si<lc ot'the hody. In some manner which is not i)erleetiy uiidcislood, liut in whicli preser- 
vation of muscular tone is probably concerned, the co-<)perati( I the ( rKliclhun is rcipiiicd if 

movements initiated in the motor area of the eerebrinn are to be ear ii( il out in :i co-nKliiMilc rMannii . 

Not oidy n)usl these two sets ol' impulses reach the brain, but the parts of the brain, 
cerebral and cerebellar, whieli lorm their destiiudion. nmst also be intact if volmUary 
movement is to be carried out with accuracy and co-ordinal ion. 

From the clinical point of \ iew it is necessary lo ascertain in the liisl phice ululher a 
patient is ataxic, and in the second whether the ataxy can be allriliuted to tin- loss ol the 
sensory or non-sensory alhrcnl impulses. In some cases the alaxy is obvious : in others 
it can be <Ieteeted oid\- by the <ar(lul applicaliou ol (crtain tests. I'or instance, a patient 
may walk into a well liiibled room with perfect case anil without anything rciu.irkablc 



56 ATAXY 

in liis unit, Ijiit if he is asked to walk along a line, placing one foot exactly in front of another, 
he may at onee display his lack of co-ordination. Such ataxy is just as important from a 
diagnostic standpoint as the imperfect attempts of an advanced tabetic patient to walk 
even when supported by companions on either side. It is the quality and not the quantity 
of a defect which gives the needed information. 

The eo-ordin^tion of movements performed by the up]>er extremities must also be 
investigated with the same care. The jjatient may handle his stick in (piite a natural 
manner, but if asked to unbotton and button his coat, to touch the ti]) of his nose with the 
tip of his linger, to write, etc.. he may fail to convince the observer that his control of fine 
movements is up to the normal standard. 

Having ascertained the existence of ataxy, the next ste)) is to decide whether it is 
dependent on the loss of sensory or non-sensory afferent imiiulses, or on the imperfect 
function of the cerebrum or cerebellum. If the ataxy is due to loss of sensorj' impulses, 
it will lie increased by the loss of visual impulses brought about by closing the eyes. It 
will also be ])ossible to demonstrate the loss of sensorj' impulses by asking the jiatient to 
describe the position of a liml^ with his eyes closed after it has been moved by the observer. 
When these two tests are i30siti\c. it may safely be assumed that the lesion affects the first 
set of impulses or their cerebral destination. 

If. on the other hand, the ataxy is uninfluenced by closing the eyes and the patient 
is perfectly accurate in describing the position of his limbs, it is probable that the cerebellar 
tracts are at fault, or the cerebellum itself. 

For further localization of the lesion in any i)articular case it will be necessary to take 
into account concomitant phenomena. 

Interference with the passage of im|)ulses necessary for proper co-ordination may be 
l)rovokc<l by lesions in (1) The /ifiijiliciiil nerves : (2) The spinal cord : (3) The brain-stem ; 
(4) 77/c cerebrum : and (.5) Tlie cerebellum. Let us now consider the effect of lesions in these 
different regions, iuid the diagnostic evidence as to their localization afforded by ataxy. 

1. Peripheral Nerves. — A severe lesion of a peripheral nerve must lead to ataxy of 
movements performed by the muscles to which it is distributed ; severe lesion will also 
paralyze the muscles, however, and thus prevent any ataxy being demonstrated. Less 
severe lesions, such as occur in slight cases of perijjheral neuritis, allow of some volimtary 
movement, so that ataxy becomes demonstrable. Thus a case of periijheral neuritis of 
alcoholic or diphtheritic origin may show impaired strength, together with ataxy in all 
four limbs. The diagnosis of a peripheral nerve affection in such a case will depend on 
the following points: In the first place, the .symptoms will be found to be symmetrical, 
and in the affected limbs the impairment of strength will be most marked in the extensors 
of the wrists and ankles. Sjicuiuily. slight ana'sthesia to cotton-wool may be detected 
over the glove and stocking areas. ^Vith regard to pain (p. (i06), there may be blunted 
cutaneous sensibility to the prick of a pin over the same area, but almost constantly, deep 
pressure on the affected muscles will establish the fact that these tissues are abnormally 
sensitive. This is a most imjiortant point in diagnosis, because it strikes an essential 
distinction between cases of ataxic peripheral neuritis, sometimes described as pseudo- 
tabes, and cases of true siiinal tabes, in which it is an almost invariable rule to find 
diminution or loss of painful sensibility on squeezing the muscles. In the third place, the 
tendon reflexes will be markedly diminished or completely absent, while the plantar reflexes 
will probably be unobtainable. Finally, the use of electrical currents upon the muscles 
« ill show that the response to faradie ciu'rents is materially lessened or abolished, and that 
the contraction excited by the make and break of the galvanic ciu'rent may be of the slow, 
worm-like type so characteristic of the reaction of degeneration (p. .58i). 

The ataxy of peripheral neuritis has in itself no reliable characteristic to distinguish 
it from ataxy due to spinal disease. That it is due to a lesion of the jjcripheral nerves is 
concluded not from the nature of the ataxy, but from the presence of other syniptom>. 
also referable to interference with the functions of the nerves. The gait is imsteady. and 
the patient keeps his legs apart in order to lessen the tendency to lose his balance. The 
clumsiness of the upper extremities may be demonstrated by his inability to bring the 
first finger of one hand accurately into ajiposition with that of the other, or to touch the 
tij) of his nose with either. Both the imsteadiness of gait and the awkwardness of the 
fingers are exaggerated if he attemj)ts to walk, or Qurry out movements with his hands 



ATAXY 57 

when his eyes are closed. A tendency to high-steppage will be noticeable in walking if. 
in addition to the ataxy, there is well-marked paresis of the dorsiflexors of the ankles. In 
such a case the jiatient is obliged to lift the feet to an nnvisiud height in order to clear the 
ground . 

•2. Spinal Cord. — The ataxy due to disease of the s])inal cord is seen best in tabes 
iliiisfilis. in which malady degeneration of the (josterior colunm ascending tracts occurs 
early, and in wliicli. consequently, the patient does not receive the normal impulses from 
the muscles, tendons, and joints so necessary for the preservation of his sense of position 
and movement. Contrary to popular ideas, gross ataxy is met with only in a small pro- 
portion of the cases of this disease, and it is often necessary to apply delicate tests to 
demonstrate its presence. The patient's gait may not be remarkable in good daylight, 
but he may complain of its uncertainty in the dark, or he may be obviously ataxic with his 
eyes closed. Another patient may have noticed nothing amiss with his walking in the 
ordinary way, but if he is asked to follow a line on the floor, placing one foot exactly in 
front of the other, his impaired jiower of balance will become apparent, especially if he is 
directed to accomplish this test with his head raised and his eyes fixed on something in 
front of him instead of ujjon his feet. 

In cases of moderate ataxy the gait and stance of the patient are remarkable for the 
wide base he assumes, and his tendency to guide his feet by means of his vision. Romberg's 
sign can be obtained easily. This sign is not diagnostic of tabes, as is so often assumed, 
but is merely used for the purpose of ascertaining whether the removal of visual impulses 
will convert a condition of stability into one of instability. Many if asked to describe 
Uomberg's sign, reply, " You direct the patient to put his feet together and close his eyes ; 
if he sways or falls, the sign is present." This is obviously incorrect, because the patient 
may sway even before his eyes are closed. In order to test a patient for this sign, he nuist 
be directed to stand with his feet as near together as he is able to do with steadiness, and, 
having established his stability in that position with open eyes, he must be told to close 
the latter. If he sways or tends to fall, it is clear that he had been depending on his visual 
impulses, and that, without their aid, the im])idscs derived from his legs and trunk were 
insullicient for the jjreservation of his equilibrium. We have in this test, therefore, a 
valuable method of ascertaining whether the function of the posterior columns is being 
carried out normally. 

'i'o judge from the descrij)tions given in some text -books, the typical gait of tabes is 
one in which the legs arc thrown into the air and the Icct brought to the ground with a 
more or less noisy stamp. As a matter of fact, this type of gait is seen only in a small 
proportion of cases, and is rarely observed cxcc))! when the |)alient is depending for sujiprjrt 
either on :i couple of sticks or on one or two attendants. In other wiirds. he has become 
so ataxic that he cannot walk unsupported, and, being suj)porteil. he no longer attempts 
to control the exuberance of his leg movements by means of his sight. 

Tabetic ataxia in its moderate and extreme degrees can be dcnKinstr.ded when the 
patient is at rest in bed. by asking him to carry out accurate movements with his hands 
and feet with and without the aid of his vision. In slighter degrees the fact that the ataxia 
is de|)endent on interference with his sense of position and movement may be proved by 
asking him to describe the position of a linger or toe which the observer moves in dilierent 
directions,^ .Sometimes it is as well in testing this sense in one limb to ask the patient ti) 
place the corresponding limb in llic s;nii<' positinn. when the error will be made more obvious. 

The diagnosis of tabes eaiiiml be in:ide Iroin I lie character of the ataxy alone, since in 
nllicv diseases, such as Krie<lrci<'li's ataxy, disseniinaled sclerosis, or cdMibincd degenerMtion 
lit the cord, there is or may be sclerosis of tlie ])oslcriov columns resulling in similar 
inco-ordination. It is iinportanl, Iherelore. to rciiicinber thai in tabes llie poslerior roots 
are allcelcii :iko. and IIimI IIk re is vei'\- ollin sonic iiilci rncncc willi olhcr alliiciil impulses, 
especially lliosc which coiiNcy sensations of pain IroTO the iniiscjcs and skin, and those 
which are conc<rncd with the deep rellcxcs and the iiiaintcnancc of muscular lone. Thus, 
in this disease one of the earliesi symptoms is relative analgesia to pin-piicks and to deep 
pressure on tin muscles in the lower extremities ; at the same lime it must not be I'orgollcn 
that the tabetic phenomena may be limited to the upper extremities (cervical tabes). 

In Frinlri irh's iiln.)//. ilissrinhiiilfil .scli ri}\is. and olhcr spinal disease, as well as in some 
cases of lalics, llic alaxx' due to llic lesion ol Ihc posterior colninns may be coinplicaled 



58 ATAXY 

and intensified by the faet that there is also interferenee in tlie patli of tlie non-sensory 
afferent impulses, which pass from the extremities to the cerebellum via the ascending 
cerebellar tracts in the spinal cord. If this form of ataxy is present, the help which the 
patient derives from vision for the purpose of controlling his inco-ordinate movements is 
largely discounted, and he may be as ataxic with open as with closed eyes. 

In some lesions, sucli as those resulting from syringomyelia or nav groivths, only one 
side of the cord may be affected, and a Brown-Sequard form of paralysis be exhibited (p. 497). 
II tlie paralysis is not complete, some ataxy may be observed in the paretic limb. 

3. The Brain-stem. — Lesions of the medulla, pons, or crura may produce ataxy if 
they interfere with tlie passage of either sensory afferent impulses to the cerebrum or non- 
sensory afferent impulses to the cerebellum. The cerebellar imjjulses can be interfered 
with only at the medullary level ; that is to say, before they have passed into the cerebelhini 
via the inferior peduncle. A good example of hemiataxia of this origin is afforded by any 
case of thrombosis of one posterior inferior cerebellar artery. This uncommon condition 
affects the structures on one side of the medulla, and is characterized by hemiataxia of the 
homolateral limbs, together with loss of sensibility to pain. heat, and cold, on the contra- 
lateral side. The ataxy is of the cerebellar type ; that is to say. it is not associated with 
loss of sense of position and movement in the affected limbs, and is little influenced by 
closure of the eyes. Above the medulla, lesions which are capable of producing ataxy by 
interfering with the sensory impulses from the muscles, joints, and tendons, usually cause 
paralysis of the same parts, so that the co-ordination is more latent than real, and therefore 
of little diagnostic importance. 

4. The Cerebrum. — From the basal ganglia to the cortex, the path of the afferent 
ini])alses necessary for co-ordinate movements lies near to that of the efferent impulses 
from the motor area, and it is only rarely that lesions affect the sensory fibres and leave 
the motor intact. Every now and then, however, a patient complaining of loss of use of the 
limbs on one side, is found on examination to be suffering from imjjaired sense of position 
and movement in those limbs rather than from paralysis. His co-ordination may be fairh' 
good so long as he can utilize his vision, but with closed eyes he has no notion of the position 
of his arm or leg, and no knowledge of the nature of objects placed in his hand (astereognosis). 
This may even be the case when other sensory stimidi, such as those of touch, pain, and 
heat, are appreciated perfectly. A similar condition may be observed during recovery- 
from a slight hemiplegic " stroke,' the patient displaying a degree of clumsiness and 
awkwardness with his fingers quite out of proportion to his loss of vohmtary power. A 
process of re-education for finer movements, similar to the education of early life, is necessary 
before he is able to overcome this form of ataxy. 

Ataxic movements are not imcommon in the subjects of infantile hemiplegia. The 
hand on the affected side may be permanently clumsy and incapable of carrying out the 
delicate manipulations necessary for \vriting, sewing, etc. In other cases all voluntary 
efforts are interfered with by the constant presence of involuntary movements of an 
athetotic, choreiform, or trenuilous character, sufficient to prevent their attaining any 
dexterity. 

Whatever the nature of the lesion, cerebral ataxy is generally characterized by its 
hemiplegic distribution, and by its increase when the eyes are closed ; generally the loss 
of im]julses suliser\ing the sense of position and movement, and often of other sensory 
impulses, can l)r demonstrated by suitable tests. 

5. The Cerebellum. — Cerebellar ataxy may be unilateral, as in some cases of tumour 
of one lateral lobe, or bilateral, as in the acute cerebellar ataxia of children due to encephalitis. 
In vmilateral cases the ataxy is most marked on the same side as the lesion, and is associated 
with hypotonia and some paresis of the affected limbs. On the other hand, it is important 
lo note that the reflexes on the affected side are normal, that the ataxy is not accompanied 
by any loss of sense of position and movement, and that closure of the eyes does not 
materially increase the patient's disal)ility. The ataxy often differs from that due to 
disease of the posterior spinal colimin in that it is complicated by vertigo. This may take 
the form of a sensation of rotation on the part of the patient, or of rotation of surrounding 
objects, sometimes of both. The vertigo and the ataxy are generally nuich less noticeable 
in the recvnnbent position. The cerebellar gait resembles that of a drunken man : the 
l)atient reels from side to side, with a general tendency to deviate or fall to the side of tlie 



atkdi'hy. -.muscular 



59 



lesion if only one lobe is affected. He is unable to balance himself properly on tlie homo- 
lateral foot, and his manual dexterity is iniijaired, so that he may be unable to iced or 
clothe himself. The ataxia is not always limited to the trunk and limbs, but may affect 
the tongue, lips, palate, and vocal cords, so that their movements may be controlled 
imjierfeetly, and a characteristic " cerebellar articulation " attracts attention. Finally, a 
lesion of the cerebellum sufficient to cause ataxy nearly always causes nystagmus also, 
which, in disease of one lobe, is more marked during deviation of the eyes to that side. 

(i. Hysterical Ataxy. — Ataxy is sometimes hysterical, and may then be the only 
disorder of function exhibited by the patient, or may be associated with hysterical hemi- 
plegia, paraplegia, hemiana-sthesia, etc. The diagnosis depends partly upon the absence 
of signs of organic disease, partly on the presence of other hysterical stigmata, and partly 
on its character. For example, we may cite the case of a boy who, when lying in bed, was 
able to feed himself and to carry out all movements of his upper and lower limbs with 
perfect accuracy, but who, when placed on his feet and told to walk, displayed the wildest 
inco-ordination and loss of equilibrium. It was noticeable, however, that he always reached 
some chair or bed on which to collapse finally, even when jilaced in the middle of the room 
at sonic (listance from any support. It would, of course, be unjustifiable to apply this 
last test before the observer was satisfied from careful examination that there were no 
signs of organic disease. E. Fai(j>iliar liiizuird. 



ATHETOSIS. -(See Contkactidn-s, 



Kil.) 



ATROPHY, MUSCLLAR.- Muscular atrophy is often merely part of a gcncnil 
<caslhig of llic ii-holc lioilif, flue either tt) chronic lesions such as carcinoma, sarcoma, tuber- 
culosis. syiJhilis, malaria, ulcerative colitis, marasmus, starvation, hepatic abscess, cirrhosis 
of the liver, diabetes, anorexia nervosa, or to acuter maladies, such as diarrhoea and vomit- 
ing, ptomaine ])oisoning, typhoid fever, dysentery, cholera, and so forth. The history, 
and the other symptoms in the case, will 
usually serve to indicate these. If any doubt 
remains as to whether the atrophy is neuro- 
trophic or not. the electrical reactions will 
be tested : there will be no reaction of 
degeneration (H.D.) when the atro])hy is 
merely part of a general wasting, whereas if 
— as might be the case in a diabetic jjaticnt. 
for instance — there is peripheral neuritis in 
addition, this will be indicated by a partial 
or coini)letc H.I). (Sec Hi; action oi- 1)i'.- 

GK.NKRATION, p. ')X2.) 

In the next i)lacc, I he atrophy may be 
tlu' result of ilisiisc. Organic disease of the 
nervous system may or may not be present 
at the same time : the patient may be bed- 
ridden IroTii locomotor ataxy, for example, 
or from guicral paral\sis of the insane : and 
the muscles ol the limbs may coiis(((Uentl\ 
become so thin that peripheral neuritis or 
degeneration of the anterior cornual cell-, 
may be siinulaled, and a determination ol 
the absence of H.I), may be the only means 
of excluding these. II is important to re- 
member that in the /jiiiiifiii/ iiiiisciildr di/s- 
Irophif.i, whether of the pseudo-hypertrophic, 
the juvenile, the infantile, the facio-scapulo- 
humeral or I,ari<loii/y - Dcjerinc or other 
types, there is no reaction of degcneral ion, 
the electrical responses and the supcrli(i;il and deep reflexes remaining normal in type, 

llioiiyli liny (llniiiilsli in (i<'j,rrce ,is llic an nl of muscle grows less and less, until finally 

""I"' i"" no iriiiscle to respond al all. 'I'lie primary nniscular dystrophics (j). 5i:i) are 




60 



ATROPHY, MUSCULAR 



com])aratively easy to diagnose, however, on account of their insidious onset in cliildren, 
tlieir slow but progressive downhill com'se, their occurrence in different members of the 
same family, the absence of sensory disorder, and the absence of R.D. They are distin- 
guished from the iiifiiiilUc paralysis which results from acute anterior poliomyelitis (Fig. 19) 
by the latter having a sudden onset, R.D. at its height, whilst the resultant wasting does 
not advance progressi\ely, but after recovering to a certain degree, tends to remain 
stationary. 

Pcri])heral neuritis is distinguished from |)riniarv muscular dystrophy by the history 
and course, and by the presence of R.D. at some period of the malady. Two other affections 
that may be confused with a primary museular dystro]>hy. ])articularly as they also are 




Fiij. L'li.— Tuorh- iMTi-n 


■;,1 tvp.-' ot nouro-nniscn 


ilystrophy— early ; tlir |.;ii 


iriit 1- thf voiitiger iM-otl 


of the girl in -/■'"/. '1. 


\'iti ilir iilantar-flexion 


the bin toes an-l Hir , 


t,.i'i>iii_- of the feet; t 


calves are not yci \\;i-!iil 






le boj- ill Fi:j. 

ajvnuced stage 

led to the calves, 



hereditary, begin insidiously at an early age. and slowly advance — arc Fii('(liricli\-: atd.ry, 
and Tootli's peroneal ti/ite (if jiroiire^siie niiisiiihir ahophi/. l^acli of these may cause talipes, 
moreover, and therefore shnulate infantili |KiiMlysis. i \(( |il that in the latter the talipes is ■ 
generally one-sided, whereas in the other two it is bilateral. In Friedreich's ataxy (see 
!>. 51".i) there is no real wasting, but rather a lack of development. Tooth's peroneal type 
of )irogressive muscular atrophy is apt to come on after some febrile malady such as measles 
or whooping-cough, the lirst thing noted being inability to dorsiflex the big toe, which 
hangs down in a way that is the exact converse of its erect position in Friedreich's ataxy 
(Fig. 20) ; the paresis takes months or years to spread to the rest of the legs, and finally 
to the hands (Fig. 21 ), the slowness of the ]5rogress and the absence of sensory symptoms 
showing that it is not peripheral neuritis, whilst the R.D. in the affected muscles excludes 



ATROPHY, MUSCULAR 61 

ii primary muscular (lystr()])liy. The lesion is in the anterior eorniial cells and starts in 
the lumbar enlaruement. The knee-jerks are retained until the ()uadrice])s of the thigh 
is involved. 

Local muscular atro])hy may be due to tliscasc of the pnrls hciwatli. as in the case of 
the pectoralis major, the supraspinatiis, the deltoid, the infraspinatus, and other shoulder 
muscles when the imderlying luni; is the site of active phthisis. Similar local atrophy 
results very ([uickly from acute and subacute affections of joints, es])eeially in the muscles 
whose origin is above the affected joint. The gluteal atrophy associated with tuberculous 
hip-joint is well known : similarly, knee-joint disease leads to thigh atroi)hy, elbow disease 
to atrophy of the muscles of the upper arm, and so on. The same applies to the effects 
of fractures, new growths, sprains, and splints ; the atrophy is sometimes so rapid that 
some think it cannot be due sinijjly to disuse, but must have a neuro])athie factor also. 
The affected muscles present no R.D., however. One jjarticular form of paralysis 
associated with the use of splints merits special mention, namely. Volckmann"s paralysis 
of (he forearm. (See PAnAi.vsis op the Uppf.k Extremity, p. .508.) 

Hemiatrophy of the face or trunk is generally congenital, and the diagnosis is not 
diHieult (see p. 4<)4). 

If it can be decided deflnitely that there is some nervous cause for muscular atrophy, 
the best proof of which is the detection of partial or complete R.D.. the diagnosis lies 
between one or other of the following conditions : — 

1. Causes in the Spinal Cord. — 

Progressive muscular atrophy A few cases of transverse I Tooth's peroneal ty|)e of )iro- 
Aniyotropliie hitcnil sclerosis i myelitis gressive muscular atro|)hy 

Syriiigomvclia | Acute anterior ])olioniycIitis 

•_'. Causes In the Peripheral Nerves. 

TaiiKMirs of the CMiula ('(iniua New growth (iummata, etc., involving the 

Pelvic tumours involving the Accessory cervical rlh. (((■., cranial or other nerves 

huiibo-sacral plexus pressing on the Inachial Injury to pcripluial nerves, 

Sciatica pk-xus I ineiuding the eUccts of callus 

Aneurysm after fractures 

Peripheral neuritis, of which the following are some of the causes : — 

Certain inorganic chemical Certain severe ana-mias : Mcii-hiri 

substances, notably Pernicious anaTnia Sy|ihilis 

I-ead " Splcno-nieilMllary leuUa'Uiia Typlioid lever 

.Arsenic I.\ rn|ihatic Icuk'aiiiia Inllucnza 

Mercury Ilnd^kin's disease Oral sepsis 

Splenic auicinia Certain eoiistitntional diseases 

Certain or;!anie chcMiical conj- Certain niicroliial ay allied sonictiines attributed l.i 

pounds, notably liixins endogenous poisons : 

Alcohol I)i|ihthcria Gout 

Ktlier Leprosy I Diabetes mellitus 

Carbon bisnlpliide Malaria ! Pregnancy 

Nai'ldlia I Chronic pya-niia Other eauses as yet undeter- 

I Infective endocarditis niincil. 

In arriving at a diagnosis in a particular case, it is important not to use the term 
' lutuitis ■ luitil all the other possible Icsiiuis have been excluded. Tooth's peroneal lyi)C 
ol progressive muscular atrophy and acute anterior ])oliom\ clil is have already been 
iliseusscd. The Udler is sometimes regarded as essentially a disease of early life, but it is 
important to renu^mber that it is by no means impossible for it lo affect an adult, in whom 
the symptoms and results may be precisely similar to what they wotdd l)c in a child. 

I'rdfiirnsivc muscular (ilid/ihi/ is a disease of adults. It shows no particular tendency to 
occur in several members of the same family. It begins insidiously, and advances slowly 
for months and years, affecting lirst the small nuiscles of the bauds, causing alrophv with 
H.I), iiijlhe interossei and in the muscles of the Ibcnar and h\pothciiar cmineuees : the 
p<'i-Mliar deformilv .|es( libcd as • main-ciinriHe ' results (p. to:)). In I lic' course of months 
Ibc paresis spreads from the bands to the forearm, and lalcr to llic upiicr arm. Disease 
of the pcripluTal nerves, such as the ulnar, is cxcludc<l by the fact that the paralyzed 
umseles are not all supplied from the same nerve trunk -tlu- thenar nmscles supplied li\ 
the median lieiiii; alleetcd cipi.ally with the bypo-tlu'iiar supplied by Ibc ulnar. All Ibe 
muscles bcldw the wiisl are iuvoKcd more or less togclbir. Ibcn all Ibe nuiscles below the 



62 ATROPHY. MUSCULAR 

clliow, and so on; this paralysis of associated groups of muscles as distinct from muscles 
NU|)])lied by the same nerve, at once suggests a progressive degeneration of the anterior 
ciirnual cells of the cervical enlargement of the cord. Disease of the brachial plexus 
^v()uld be excluded first by the fact that the lesion is bilateral and symmetrical, and 
secondly by the absence of pain or other sensory disturbance. The ])atholog>' of the disease 
is analogous to the nuclear cell-degeneration in the medulla oblongata that leads to bulbar 
(labio-glosso-pharyngo-laryngeal) paralysis : and indeed, progressi\e muscular atrojihy 
may either follow or be followed by bulbar paralysis. 

If. at the same time that there are the signs of progressive muscular atrophy in the 
hands, there is also spastic paresis of the legs, with no wasting, but increased knee-jerks, 
ankle clonus, and extensor plantar reflexes, the onset having been quite gradual, without 
sensory disorder, and without bladder or rectal trouble unless the disease has reached quite 
a late stage, the condition is amyotrophic lateral sclerosis. 

It is important that the character of the onset and the absence of sensory symptoms 
be insisted on, in order to exclude syringomyelia and anomalous cases of transverse myelitis. 
Si/ringomyelia is rare, but it has one very characteristic feature, namely, the preservation 
of ordinary cutaneous sensibility with the loss of power of distinguishing heat from cold, 
or pain from touch, in some part of the limbs or trunk. There need be no other symptom 
than this dissociation of sensations, or skin lesions in the jiartesthetic parts may be a 
prominent feature — Morvan's disease ; if the enlargement in and around the central canal 
of the cord displaces and destroys the anterior cornual cells in the lower part of the cervical 
enlargement, progressive muscular atrophy is simulated : if at the same time the bulging 
of the central canal and the changes around it cause compression of the crossed pyramidal 
tracts, there will be all the motor symptoms and signs of amyotrophic lateral sclerosis, the 
diagnosis being only possible when the sensory symptoms are typical. 

It is generally stated that transivrse myelitis causes spastic paraplegia without muscular 
wasting or R.D. This is in the main true, because the few anterior cornual cells destroyed 
by the transverse softening of the cord in the commonest site, namely, the dorsal region, 
correspond to an iMtcrciistal or abdominal segment, the wasting of which is difficult to 
detect. If, howcxci. tin- Iransverse myelitis occurs so high up as to involve the lower part 
of the cervical eiilargnmnt — to involve the cord yet higher up is incompatible with lite, 
because both the intercostals and the phrenic nerves would be paralysed — a certain niunber 
of the anterior cornual cells sending motor nerves to the hands and arms would be destroyed, 
the result being a main-en-griffe like that of progressive muscular atrophy : and the 
simultaneous interference with tlie crossed pyramidal tracts would produce a picture 
identical at first sight with amyotrophic lateral sclerosis. Not only, however, would there 
very likely be impairment of all forms of sensation as well as paresis, in a case of transverse 
myelitis, but instead of the onset being gradual and the progress a steady advance downhill, 
as in progressive muscular atrophy or amyotrophic lateral sclerosis, the onset would have 
been comparatively rapid, followed by a cessation or even by an improvement if the jjatient 
lived. Similarly, if transverse myelitis occurs so low down as to involve the lumbar enlarge- 
ment of the cord, it would cause, not spastic paraplegia with increased knee-jerk, ankle 
clonus, extensor plantar reflex, no wasting and no R.D, : but absence of knee-jerk, no 
ankle clonus, no extensor plantar reflex, marked muscular atrophy of the legs, with R.D., 
]jaraesthesia, bladder and rectal trouble. The involvement of the sphincters in such a 
case would be of considerable aid in excluding peri])heral neuritis ; whilst Tooth's peroneal 
type of prog^essi^'e muscular atrophy and acute anterior poliomyelitis would be excluded 
not only by the para;sthesia, but also by the history of the mode of onset and the course 
of the maladv. 

A timiour involving the caiida equina is rare, but it is not altogether diflicult to diagnose. 
It may be more diflicult to determine the nature of the mass — gunmia, glioma, primary 
sarcoma, secondary sarcoma or carcinoma — than its site. The onset of symptoms is 
generally gradual, and one leg is aflected either earlier than, or more than, the other. 
Weakness in the leg, together with severe pains both in it and in the lower part of the 
lumbar region of the spinal column, will be followed by muscular atrophy and R.D. 
Sciatica may at first suggest itself, until it is found that neither the pains nor the paresis 
correspond to one single nerve ; and when the disease progresses and the other leg is 
affected, anaesthesia supervenes upon the paralysis. The site of the pain over the region of 



ATROPHV. .ML'SCULAR 63 

tlic Cauda cfiuina i^ an iin|jiirtant jjoint in tlu- diagnosis, whilst rectal and ]jossibly \aginal 
examinations arc essential for the exclusion of a pelvic mass — snch as carcinoma of the 
rectnm, uterus, or ovary, a flbromyoma, a cyst, a sarcomatous, gummatous, tuberculous, 
or inflammatory mass, or e\en a displacement of the womb — which, by interfering with 
the nerves at the back of the pelvis might produce very similar symptoms. Sacro- 
iliac joint disease can generally be excluded by the fact that the pains arc not definitely 
referred to the joint, whilst any wasting that might be associated with disease of that 
joint would not be accompanied by R.D. 

Srialicii (p. 438) does not always give rise to wasting of the corresponding muscles : 
but sometimes it does, and occasionally it nuiy do so bilaterally, with R.D. The localiza- 
tion of the pain, tenderness, and atrophy to the parts supplied by the great sciatic nerve, 
without affection of other nerves and muscles in the leg or calf, would point to sciatica, 
especially if the lesion was unilateral, and if the patient, though imable to flex his thigh 
to a right angle with his abdomen at the same time that lie keeps his knee extended, can 
extend his leg backwards at the hi])-joint in a way that would be impossible if he had a 
psoas abscess ; and if he is able to bear firm backward pressure on the knee when the leg 
of the -affected side is flexed and outwardly rotated in such a way that the foot lies across 
the opposite knee — a test which will exclude hip-joint disease. 

When the lesion is a thoracic (nieiiri/.im or neoplasm, or :.n accessory cenical rib pressing 
on or involvinti the brac)iial plexus, the wasting is almost certain to affect one arm only, 
or one arm mudi more than the other, and the diagnosis will be made by j)hysical cxamina- 
tioM of the thorax, assisted by the .r-rays. 

The only cranial nerve paralyses that are likely to be associated with marked atrophy 
of muscles, are those of the seventh with facial atrophy (]>. tOU). and of the twellth with 
atrophy of the tongue. 

Injaries io periplicral nerves, or inclusion of the latter in callus, will generally be 
diagnosed by the history, and by the fact that in distribution the nuiseular atrophy and 
H.l). eorres])ond accurately with one or more of the peripheral nerves that may have been 
di\ided or otherwise injured. 

If all the conditions described above can be excluded, it is probable that the cause 
of the nuiseular atrophy is some variety of peripheral neuritis. To merit this diagnosis, 
the affected muscles shoukl be multiple and .symmetrical : partial or com|)lete R.D. should 
be obtained : there nuiy or may not be sensory changes ; the reflexes, both superficial and 
deep, are for a short time exaggerated, and then become deficient or <lisai)pcar altogether 
for the time being. Wasting may be extreme, but the tendency is for slow recovery to 
ensue, improvement beginning to set in some three or four months after the neuritis ceases. 
.Sometimes the nature of the case is obvious, but it is often easier to diagnose peripheral 
neuritis than to discover its exact cause. The different conditions that may i)roduee it 
are cnutncrateil above. In diagnosing between them the history is very iniporlant. Kor 
instan<(', if the patient has never been abroad leprosy and hcri-tieri are unlikely, whereas if 
he has been abroad amongst lci)ers, and if he has areas of ana'sthesia without nuieh 
paresis, with or without the characteristic nodules and bosses of subcutaneous infiltration 
{Fin. l^IJ. p. lot), followed by ulceration and necrosis, the diagnosis of leprosy will at 
once suggest itself. The chief dilliculties will perhaps be to exclude syringomyelia on the 
one hand and tertiary syphilis on the other. The good clfeets of treatment by iiotassium 
iodide and mercury may assist in deteeting syphilis, and \Vasseruiann"s reaction may be 
positive : in syringomyelia there is little or no loss of eulaucous sensibility like there is in 
leprosy, though there is loss of power to distinguisli lii.il licmi viM. and pain fniiii touch. 
The ultimate lest of leprosy would be to excise a small poitinii nl tlu allrcted tissue and 
to examine it for the acid-fast leprosy bacilli. 

Iliii-hcri is sometimes seen in this country, geiurally in patients wlm liaxc come into 
lort in a ship from the Kast : several of the crew have generally been aflVctcd at the same 
time, some nuiy have <lied : the peripluTal luurilis and muscular wasting will often be 
associated with (edema, and there is often a history that the dietary has consisted of 
"Iceorlieated rice. 

I'he presence or absence of gly<MisMria will scrxe to diagnose or cNelude ilialictic 
neiirilis. |.i,ss of knee-jerk in dialietis Miellitus is cdMiparal i\ ily eoinnion, but e\lensi\e 
peri|)li( lal ncmitis is i Ii rarer. It is Mssdcialed with jiain and par.istliisia as well 



64 ATROPHY. MUSCULAR 

as paresis and nniscular atiopliy, and it affects the limbs, especially the legs, rather than 
the trunk. 

Gout as a cause of peripheral neuritis is always open to doubt, for often the nein-itis 
of a gouty subject is really due to the indulgences that brought on the gout. Difliculty 
may also arise in attributing a neuritis to pregnancy even when the patient is. or has been 
recently, jjregnant. 

In the case of blood diseases it is important to bear in mind that these are usually treated 
with arsenic, so that the peripheral neuritis may be due to the treatment rather than the 
disease. This will be rendered the more probable if there are or have been other symptoms 
of subacute or chronic arsenical poisoning, such as coryza, nausea, \omiting, abdominal 
colic, diarrhoea, headache, pigmentation of the skin not unlike that of Addison's disease, 
hyperkeratosis of the palms and soles, or herpetiform eruptions, AVith arsenical neuritis the 
limbs are involved most, particularly the legs, and there are pains and paraesthesia as well 
as jjaresis. The blood diseases may themsehcs cause peripheral neuritis, however, just as 
severe anfemias, such as pernicious ana-mia, may cause degeneration in other parts of the 
nervous system also, notably in the long tracts in the spinal cord, with consequent sensory, 
ataxic, or paretic symi^toms. varying with the ])arts involved. If the jjeripheral neuritis 
occurs early in the blood disease, the latter may not come to mind as a possibility. 
A blood-count is essential (p. *24). OligocythaMuia with high colour index, no leuco- 
cytosis, a relative lymphocytosis, and the presence in blood iilms of a preponderance of 
megalocytes. are changes characteristic of pernicious ancemia, in addition to which the 
primrose-yellow skin may be typical. Great increase in the total number of leucocytes up 
to anything from .50,000 to 1.000,000 per c. mm. would suggest Icucocytlia'niia : if this were 
the spleno-medullary form, myeK)cytes would probably be 30 per cent or more of all the 
white cells seen in films, whilst in tlie lymphatic form the lymphocytes would similarly 
amount to 90 per cent ; in both forms, jjarticularly the siileno-medullary, the spleen and 
liver would be big, whilst in the lymphatic tyjie there would ])robably be general enlarge- 
ment of the lymphatic glands. 

Ilodgkin's disease or lympliadcnoma suggests itself when the s])leen and many of the 
lymphatic glands are enlarged, without any characteristic blood changes — at most a simple 
auicmia without leucocytosis, with relative lymphocj'tosis, and an occasional myelocyte, 
basophile corpuscle, and nucleated red cell in films. Splenic ancemia is a doubtful entity, 
the name being applied when there is simple anitmia with apparently idiopathic enlarge- 
ment of the spleen. Many such patients ultimately turn out to have cirrhosis of the liver 
— Banti's disease. Peripheral neuritis in sucJi a case may well be alcoholic. 

Malaria will be diagnosed by the history, and by the discovery of the hirmatozoa in 
the blood (p. 29). The difficulty may be to exclude alcohol as a cause for the neuritis in 
a jiatient who has also suffered from severe malaria. 

Infective endocarditis is sometimes so chronic and insidious that it escapes detection. 
Pt)ints to lay stress on are simimarised on p. 34. 

It may not be easy to convince onselt that some other cause of chronic pycrniia, whether 
uterine, pelvic, pulmonary, oral, or otherwise, is the cause of peripheral neuritis in a given 
case. The same applies to sypliHis, especially if the patient is also addicted to alcohol. 

Influenza is not to be diagnosed as the cause vmtil every other jiossible exjjlanation has 
l)een exhausted ; it is too easy to attribute things to influenza. Peripheral neuritis from 
typhoid fever generally arises as a direct sequel of a typical attack confirmed by Widal's test, 
so that the diagnosis is not difficult as a rule. It has the same type, sensory and motor, as 
arsenical neuritis. 

Diphtheria is one of the most important of all the causes, and if the diphtheria itself 
has been slight, it may have been overlooked entirely, especially as the neuritis develojij. 
two or three weeks or longer after the sore throat. It is important, tlierefore. to lose no 
time in taking cultivations from the throat in all doubtful cases of peripheral neuritis : it 
may still be possible to find the causal organisms in swabbings. The nature of the case 
may be suggested at once, however, if there has been a nasal alteration in the voice (p. 58SI), 
or if there is an inaliility to swallow liquids owing to their regurgitation through the nose — 
e\idence of jiaralysis of the palate that is almost characteristic of diphtheria ; the pu))il 
reflexes are also apt to be affected, and the patient may be thought to ha\-e an error ol 
refraction because pjiresis of the ciliary muscle renders acconunodation difiicult oi 



PLATE VII. 

PIGMENTATION DUE TO ARSENIC 




'4 K 



ATROPHY, MUSCULAR 65 

impossible for the time beinn;. The symptoms may stop at the ])alate and eye ; but in 
bad cases — perhaps as the result of a toxin different from that wliieh directly affects the 
palate — paralysis and extreme atrophy of the limbs, without much sensory disorder, follow. 
The vagus nerves may be involved, causing tachycardia, and perhaps death ; equally 
serious may be the involvement of the phrenic nerves, with weakness or paralysis of the 
diaphragm. 

In regard to the vmious cliemicnl substances that may produce peripheral neuritis, 
iiKjuiries into tlie patient's occupation may assist the diagnosis. Workers amongst india- 
ruliber come in contact with carbon bisulphide fumes, this comjioimd being used to dissolve 
the rubber. Xtiplilliii is used extensively in some trades. The use of a chemical may not 
always be obvious until careful inquiries are made — for instance, one may not at first see 
what a person who ]]re])ares rabbit skins for conversion into hats has to do with mercury, 
until it is learned that mercurials are used to preserve the pelts. Mercurial neuritis is 
characterized by a remarkable tremor of the hands and arms, in addition to the muscular 
atrophy in the amis and legs ; there are not many sensory symptoms as a rule. Lead 
neuritis is easily diagnosed when it causes the characteristic wrist-drop, though a similar 




piiniivsis 111 I lie liand may be due to other forms of peripheral neuritis such as diplitheritic 
IFifi. 22). or to the result of compression of the musculo-spiral nerve by callus or 
(Tutch-hcad. or by sleeping with both arms across the arms of a chair — ' Saturday night 
palsy" : in fihirnbic wrist -drop all the muscles supplied by llic musculo-spiral nerve beyond 
llic triceps bcconic paralyzed, except the supinator longus and the cxiciisor ossis iiictacarpi 
pollicis, aiKJ IIk re is no sensory disorder : the escape of the supinator longus dislinguishcs 
wrist -drop due to plutnbism from that due to compression of the nuisculospiral nerve ; the 
diagnosis is confirmed by finding a blue line upon the gums and the other signs of lead 
pf)is<)iiing described on p. :( I-. 'I'he dillicully arises in less typical cases in which the lead 
causes generalized peripheral neuritis in both legs and arms, ])erha[)s without any other 
syniploins. without even a blue line upon the gums if the teeth are kept clean. 'I'he source 
<)r the lead may be very far from (ib\ious it may be some obscure thing, such as a hair- 
wash, or (he result of water contaminati<in due to electrolysis in water-pipes, the result of 
leakage in an electric main. In ease of doubt it may even be worth while to analyze the 
faices or cvajxirate down a large bulk of urine and apply the lunmonium suliihide test for 
lead to the residue : a drop or two of Ihc latter, allovved to fall into a tall glass full of 
amnioniiini suiplude, will cause a white trail l<> develop in the fluid as tlii' drop descends. 
Arseniciil nvurilis has been mentioned above (p. Gl) ; it may arise in patients who are 



66 ATROPHY, .^lUSCULAK 

taking arsenic in medicinal doses, for instance for chorea or peniicions ana'mia, or the 
j)oison may be taken unawares, as in the Manchester e]3idemic. in which fatal results foUowerl 
contamination of beer with ai-senic. It has even been held that alcohol itself is no cause ot 
peripheral neuritis, and that those patients who have developed it as the result of lonjj- 
continiicd drinkini; to excess — possibly without a single actual intoxication in the popular 
sense — owe the nerve trouble and generalized muscular atrophy, not to the chemical sub- 
stance C„H,.0, but to other bodies associated with it. Clinically, however, it is sufficient 
if the diagnosis of the cause of periplieral neuritis can be narrowed down to alcohol in some 
form or other, and for this to be possible an accurate history is essential. The greatest 
difliculty arises in the ease of secret drinkers, especially women who may ajjpear to be above 
suspicion. The neuritis is ushered in with pains and cramps in the limbs, followed by 
wasting which may reach an extreme degree : the trinik and limbs sometimes look like 
those of a i)erson who has been starved to death : if arsenic is suspected, a portion of hair 
should be sent for cliemieal analysis ; the hair of a ])erson taking arsenic stores the latter 
in proportions sufficient to allow of its detection. 

It only remains to add that there will alwa\s be some cases in \\hich the cause of the 
peripheral nem-itis fails to be found. Herbert French. 

ATROPHY, OPTIC— (See ()pnTn.\i.MOscopic Appearances. Notes on. p. 416.) 

ATROPHY, TESTICULAR.— When one testis is smaller than the other, it is first 
necessarv to determine which is the abnormal one : for when one is slightly enlarged, it may 
be regarded erroneously as normal and the other as too small. Some inequality may be 
jjliysiological. as is the case with paired organs generally. Physiological atrophy of the 
testes is apt to occur in advanced life ; it may begin as early as fifty, though many old 
men have testicles of normal size. 

A testis in an abnormal position, in the inguii\al canal f>r elsewhere, is subject not only 
to such causes of atrophy as may affect one normally situated, but ma>- also be inhibited in 
growth from compression by surrounding parts. 

The causes of atrophy of a normally situated testis may be grouped imder three main 
headings, as follows : — 

1. Interference with the Blood Supply: — 



Compression of the spermatic cord, as by an 

inguinal hernia, a spermatocele, or an ill- 

tittina truss. 
C(iiii|ir(ssiiiTi of the testicle by affections of 

tlir liniica vaginalis, such as hvdrocele or 

hainaldcrle. 



Venous stasis, tlie resuh of varicocele. 

.\s a sequel of operation in the region of the 
spermatic coril, such as those for the cine 
of varicocele, spermatocele, or hernia. 

Elephantiasis. 



2. Atrophy, after Orcliitis or Epididymitis, due to such causes as — 

(ionorrlicea I Mumps I Gout 

Tubercle .Y-rays Syphilis 

Injury | Typhoid fever | Influenza (?) 

3. Neurotrophic Causes, especially after injury to the brain or spine. 

It has been stated that the atrophy may residt from iodide of potassiimi : this is 
dillicnlt to prove, for it seldom hapjjcns that this drug is given unless there is already some 
oilier possible cause, particularly sy]ihilis or orchitis. 

In the differential diagnosis between the al)o\c causes the history is in most instances 
\cry important. 

The cause in any of the cases in Group 1 will generally be ob\'ious. It is only necessary 
to bear in mind that an operation for varicocele, for instance, may have been performed 
successfully, and the patient may thereafter contract an orchitis followed l)y tcsticidai 
atrophy for which the operation may be blamed unjustly. 

As regards Group 2. it is very doubtful whether influenza ever really ])rodueed either 
orchitis or testicular atrophy. There may be a definite history of gonorrhoea, followed b\ 
orchitis, which preceded the atrophy, and then diagnosis is easy. It is to be remembered 
however, that by no means every orchitis is gonococcal. If miunps, typhoid fever, goul 
and injury are borne in mind, these causes of orchitis and testicular atrophy will 1" 
recognized more often than they are. JMiunps is particularly apt to be overlooked : orchitii 



AURA 67 

may be the sole e\'idence of this complaint. If the patient is seen when the orcliitis 
is active, bacteriological examination of any urethral discharge is essential to the dia- 
gnosis, which depends on whether gonococei are detected or not. If gonorrlura can be 
excluded, then the diagnosis of the nature of the orchitis is arrived at by considering 
the evidence as to gout, mumps, and so on. 

It is sometimes stated that orchitis may result from strain, atrophy resulting in due 
course. There are a few cases in which, apparently as the result of great bodily exertion, 
es])ecially the lifting of heavy loads, inflammation of the testicle follows : but it is difficult 
to say that in these cases the strain alone produced the symptoms ; there is the possibility 
that there may have been residual gonorrhcca in the jjrostate or jjosterior urethra, the 
action of the strain being merely to light u)) the latent inflammation. It is possible that 
sometimes the latent infection is not gonococcal, but due to other organisms, such as staphy- 
lococci or streptococci, whilst recent observers record the bacillus coli comnumis as the 
causal organism in some cases of " spontaneous ' orchitis. 

There remain a number of cases, however, in which there is no clear history of orchitis, 
the latter having been relatively slight. Testicular atropliy will then seem to have arisen 
idiopathically, and it is important to remember how often it is the result of former injury, 
such as a kick at football, a blow from a cricket ball, contusion from falling astraddle on a 
fence or bicycle, and so on. The injury may date back to boyhood, many years before 
testicular atrophy is noticed, and it will often be difficult to ))rove that the latter was really 
due to the former. r.1 

A])art from obvious tuberculous epididymo-orchitis. transient enlargement of a testis 
is to be observed, if looked for, in tuberculous subjects ; whether this can be regarded as a 
dcMnite tuberculous orchitis or not. it sometimes results in atrophy. 

Tlie j'-rays are a possible cause of testicular atrophy, and all users of .r-rays should be 
careful to have a suitable lead shield. That sterility can result from repeated applications 
of these rays is well known. 

.\s regards (Jroup 8. the history as a rule gives the diagnosis. Remarkable instances 
have been recorded in which, within a few months of injury to the brain or spinal cord, 
particularly after injury to the hmibar vertebrje, or the occipital region of the skull, the 
glandular elements of the testicle have disappeared. A case of Kocher"s exemplifies 
this: A man. age 41. the lather of four children, fell on his head from a considerable 
height. .\t lirst he did not ajipear to be greatly damaged, but ])resently twitchings 
occurred, and the patient became unable to work. From this time on Iiis sexual powers 
diminished greatly, and his beard and iiubic hair fell out. Eighteen niontlis later this hair 
was gone compklcl\ . and about five years after the accident the left testicle was tbc size 
of a hazel nul. the right the size of a bean. llnhirt J'rnirli. 

AURA is the term applied to the inunediate prelude of an cpiUplic seizure. It is 
recognized in some form or another in about ;i() or 40 per cent of epilcplics, and with rare 
exceptions always takes the same shape with every attack in each indixidual. An aura 
may be motor, .sensory, ])sychical, visceral, or related to some special sense. A motor aiua 
may he rcpresenled by an involuntary movement of a limb or a part of a limb ; in othei' 
cases it talTcs the form of a general movement such as rumiing. .\ si'iisori/ aura is conmion. 
and is described as a pain, a numbness, or a tingling in some part of the patient's body. .\ 
psj/rliical iuna is often expressed as a vague apprehension, or an indescribable feeling, or a 
sense of unreality. .\ Tisreral aura is fre<|uent. usually as an •epigastric sensation" or 
queer feeling starting in the region of the stomach and rising to the throat, or less often as 
a pcremjjtory desire to go to stool. An aura of special sense may be olf/KiDii/. -riKiiiil. 
iKidiloi-i/. m fiii.ilnloij/ : a pleasant or unpleasant (iridui- m flavour may be pincJNcil b\ llie 
patient, or some alleralion in vision may warn liini u\' llu' onset of a sci/mc. or he may 
hear voices or some parlieular kind of soimil. 

The aura of epilepsy is. in relation to diagnosis, imporlani fr al Icasl I wo points 

of view. Ill llic lirsl place, it olleli affords a clue to the parliiular hiealily in llie brain 
froie whicli tlic ' III ' or • sloiin ' originates and spreads. This ma\ not he ol iiiiieli 
value in the case of idiopathic epilepsy, because there is no method at present known lo 
us by which the seal of the disease can be treated successfully. In tlu' ease of .buksonian 
epilepsy, on the other hand, the knowledge of the locality in which a (il is generated some- 



6K AURA 

times, although unfortunately not often, allows of benefit being obtained from surgical 
assistance. For instance, an aura may be the first symptom of the presence of an intra- 
cranial groivth. A tumour of the uncinate region of the temporo-sphenoidal lobe may be 
revealed by the presence of signs of increased intracranial pressure and the repeated 
occurrence of an olfactory aura, followed by a vague, dreamy state of consciousness. A 
lesion of one occipital lobe may be suspected from the occurrence of epileptiform fits 
immediately preceded by an ain-a in which there is loss of sight in the opposite visual field. 
An aura of pain starting in the left foot, spreading up tlie left side of the body, and 
terminating in a generalized convulsion, suggests a lesion in the post-RoIandic region of the 
right parietal lobe. Such instances of the importance of an aura as a localizing sign in 
diagnosis might easily be multiplied, but a general knowledge of the functional anatomy of 
Ihe brain will suffice to supply other examples of a similar kind to the reader's mind. 

In the second place, the importance of recognizing a subjective sensation as an aura, 
and so recognizing the existence of epilepsy in its simplest and sometimes earliest form, 
can hardly be over-estimated from the point of view of treatment. VMien a patient describes 
himself as being liable to subjective sensations occurring at intervals, and for which he 
cannot account, careful inquiry should be made as to their nature. The chief characteristics 
of an aura are: (1) Its spontaneous development without cause, generally during good 
health : (2) The suddenness of its onset ; and (3) The identity of each sensation with the 
last. It should be understood clearly that an aura may occur alone, or may be followed 
by momentary loss of consciousness (petit mal), or by loss of consciousness with convulsions 
(grand mal). In some cases an aura may be repeated with frequency for many months 
before a typical epileptic seizure supervenes, and if recognized as such during this stage, 
it is reasonable to expect that treatment will have more chance of success than at a later 
period, when the " habit " of convulsions has been established firmly. 

Finally, it should be emphasized that in cases of epilepsy the recurrence of an aura, 
even without further manifestations of the disease, is evidence that the morbid tendency is 
not controlled completely, and that discontinuance of treatment will lead to the reappearance 
of more serious attacks. E. Fanjubar Buzzard. 

BABINSKI'S SIGN — consists in a modification of the plantar reflex. In testing the 
latter the j)atient should be lying upon his back, with his legs very slightly flexed and each 
foot everted so that its outer border lies comfortably in contact with the bed or couch : 
the sole should be warm and dry ; the ankle should be gently but firmly grasped by one of 
the observer's hands, to prevent the undue dorsiflexion of the whole foot which often makes 
it difficult to decide which way the toes themselves move, wliilst the outer side of the sole is 
firmly and steadily stroked from the heel forwards with some such instrument as the butt 
end of a pencil. In healthy adults the big toe and the other toes will become plantar-flexed : 
when the great toe becomes dorsiflexed instead, it presents tlic extensor plantar reflex, or 
Babinski's sign, ^^liichever way the other toes move, it is with the direction of movement 
of the big toe alone that Babinski's sign is concerned. It is noteworthy that if Babinski's 
sign is present, the fact is usually ascertained with ease ; when there is any doubt as to 
which way the great toe moves, the plantar reflex is seldom really extensor. 

The great value of the sign is in distinguishing between functional and organic affections 
of the nervous system. If the patient is a fully conscious adult with paresis of one 
or both legs, the existence of an extensor plantar reflex is proof that the lesion is organic. 
The converse is not true ; for with locomotor ataxy, and with lower neuron affections 
such as infantile paralysis. Tooth's peroneal tjpe of progressive muscular atropliy. perijiheral 
neuritis, Landry's acute ascending paralysis, and primary nniscular dystropliics, the plantnr 
reflex is flexor if it is obtainable at all. 

Babinski's sign is seen best when there is a lesion in the crossed jiyramidal tract. Thus 
it is present in cases in which tumour, abscess, hsemorrhage, thrombosis, or embolism have 
caused hemiparesis or hemiplegia by affecting either the pyramidal cells themselves in 
the motor cortex or the pyramidal fibres in the internal capsule ; in cases of cerebellar 
tumour, owing to the fact that this, by compressing the medulla, nearly always causes 
lateral sclerosis of the cord as well ; and in cases of disseminated sclerosis, transverse myelitis, 
either primary or due to compression, ataxic paraplegia, Friedreich's ataxy, amyotrophic 
lateral sclerosis, primary lateral sclerosis, some cases of syringomyelia, and in those cases 



BACTEKIURIA 69 

of irregular sclerosis of tlie cord that may be associated with sc\erc ohgocytha?mias such as 
pernicious anjeniia. Tlie differential diagnosis of these conditions wilf be found under 
Hejiiplegia (p. £02) and Paraplegia (p. 310) and elsewhere. Babinski's sign is not found 
in those cases of hysteria that sometimes sinnilate one or other of the above conditions ; 
provided always that the ])atient is a conscious adult. This proviso is important, because 
the plantar reflex may be extensor without there being any decided changes in the cord 
or brain in infants and (luite young children : also in a considerable proportion of older 
children suffering from chorea : and also sometimes in adults during deep sleep, or under 
conditions of nnnatural unconsciousness such as that due to a general ana;sthetic, or acute 
alcoholic intoxication, or such affections as epilepsy, uraemia, concussion, saturnine encephalo- 
pathy, and in some other forms of coma. These exceptions, however, scarcely detract 
from the great value the sign has as a means of distinguishing between organic and functional 
paralysis of the legs of the upper neuron type. " " " Herbert French. 

BACILLURIA.— (See Bacteriuria. uifra.) 

BACTEHIURIA (see Plate XXVIII. p. Ol-i) is a comjjreliensive term employed to 
indicate that the urine when freshly voided contains micro-organisms. Bacilluria is a term 
of similar imjiort, but is restricted to those cases in which rod-shaped bacteria are present. 
The \:iginal segment of tlu^ female urethra and the anterior portion of the male urethra are 
n<)rniall>- inhabited by certain non-])athogcnic bacteria (chiefly cocci, such as Streptococcus 
brevis. StapliijIoioccK.s ulhiis. also varieties of Bacillus xerosis, etc.), which are, of course, 
present in urine obtained under ordinary conditions, and so constitute what may be termed 
physiological bacteriuria. Bacteriuria as a pathological condition tlue to some lesion of 
the urinary system posterior to the urethra can only be recognized with certainty by the 
examination in the laboratory of a catheter specimen of the urine collected with the most 
scrujiulous attention to asepsis : for, on the one hand, a perfectly clear acid urine may be 
hea\ily loaded with bacteria, and. on the othei-. a mine may owe its turbidity cither to 
purely physico-chemical causes, or to the growth in it of bacteria which have gained access 
after its exit from the urethra. Moreover, although the identity of the infecting organism 
may be suspected from general clinical considerations, cultivation exijcriments are essential 
in order to settle the matter beyond doubt. 

Bacteriuria may be jxrsistent and may indicate either general or local infection. It is 
a rare symptom of general infection, save one of such intensity that an acute ne])hritis, 
as.soeiated with a definite luematuria. has supervened. I'sually its appearance indicates 
a local infection of the urinarj- tract : it then occurs with greatest frequency in young 
children and ])regnant women, when the micro-organism concerned is usually B. cofi, and 
the site of the infection the pelvis of the right kidney. It is, however, met with at all ages 
and in both sexes, and many djlfercnt bacteria have been recorded as the causative faetoi's, 
and whilst the itilccliun is commonly due to some partieulav micro-organism, the possibility 
of multiple infection nuist not be forgotten —the most usual being a double inlVction due 
to H. roll communis and Streptococcus pijoneiies lotigus. 

When Intermittent, bacteriuria may indicate a general inleclion. or a local inreetion 
of some area <iistant from the minary tract, as, for exanii)le, a tonsillitis or a dental abscess, 
anil often in an obscure ease of pyrexia a bacteriological examination of the urine will well 
repay the trouble involve.l. Intermittent bactcrim-i,i. parti<iilariy of the staphylococcic 
type, is often associated with Isidncy ealcnius, and il is aKd rwit uuconmion in Cases of 
rheiimatoiil arthritis. 

Haelerinria may he a s_\ iiiolorri in : 

-I. General Infections, with oi- witliout associalid nr|i|]ritis. due to: 

Slnploeoeeus py»«cnc>, loii^r„s Sl:i|.li ylneoeciis pyojrcncs ail- 15. coli 



einnoet 



ininunis 



H. (iMial vpliosus 
M. typluiMis I .Micincocens niclilerisis 



/'? Local Infections : 

»e|ihritis, pyelonephritis. ,„■ ureteritis due to: — 
"•^"'' . H. |.neinn.mi;r (Kriedliin.ler's Sla|.l,yl.i 



H. luherciildsis 
M 



liacillus) 
Strcplocdceiis py(i;;cMcs Iciml'Ms Pn. 



70 BACTERIURIA 

Cystitis due to : — 
B. coll I B. typhosus I Staphylococcus pyogenes au- 

B. tuberculosis i Streptococcus ])yoaeues loufjus | reus 

Prostatitis due to : — 
B. coll I Staphylococcus ijvogcucs au- Streptococcus pyogenes longns 

tJonococcus I reus 

Urethritis due to : — 
Conococcus < Pneiunococcus j Micrococcus catarrlialis 

Sta|)hylococcus aureus or albus ' Streptococcus pyogenes longus , 

In tlie above table the various micro-organisms are, speaking generally, arranged in 
the order of their frequency. 

Finally, a slight and transitory bacteriurla due to B. coli commioiis, and one usually 
passing off without any treatment, can frequently be observed following operative measures 
upon the rectum or anus, or the organs of generation. 

In general infections the urine is either normal in appearance, or by reason of its admix- 
ture with blood may present any tint from " .smoky ' to bright red. The reaction is usually 
acid; often a degree of acidity is recorded which if present in an artificial culture medium 
would inhibit the growth of the infecting micro-organism. Albumin is present, varying in 
amount from a trace to 7, 8, or more parts per thousand, and microscopical examination 
of the centrifiigalized deposit shows blood-cells, renal tube-casts, and renal epithelium, in 
addition to the infecting bacterium. The clinical sym|)tonis ])resented by the patient are 
those of the general systemic infection. 

In local infections of the genito-urinary tract where infection is due to one species of 
micro-organism only, the urine jjresents a somewhat similar appearance ; blood, liowever, 
may be entirely absent, while pus when measured by the centrifuge may vary in volume 
from a trace to 10 or 20 per cent of the total bulk of urine. In the early .stages of a local 
infection, however, microscopical examination of the deposit may merely show the presence 
of leucocytes slightly in excess of normal, so that without the use of the microscope the fact 
of pyuria may easily be missed altogclher. 

Occasionally, and particularly in adult cases, it may be noted that the urine passed 
during the day is neutral or faintly alkaline — the change in reaction then being due to 
|)hysioIogical causes. In those cases where the urine is strongly alkaline the alkalinity is 
due to annnonia resulting from the decomposition of urea, not by the jiathogenic infecting 
organism but by non-pathogenic saprophytes which have gained access to the urine, either 
after it has been voided or whilst still intra vesicam. In the latter instance the contamina- 
tion may have taken place as a residt of careless instrumentation, or (as in the female) by 
continuity of surface, but it also fretjuently occurs owing to the passage of micro-organisms 
through the inflamed bladder wall from the lumen of the adjacent large intestine. 

The clinical symptoms associated with bacteriuria due to local infection vary enor- 
mously with different patients. Frecjuency of micturition, scalding, didl aching pains in 
one or both loins, with tenderness on deep jjressure over the kidney or meters, pains in the 
perineum and hypogastriiun (according to the situation of the jirimary infection), severe 
rigors, pyrexia {Fig. 193, p, 456), anorexia, nausea, and vomiting are amongst those 
commonly observed. It is important to remember its relatively common occurrence in 
children, in whom there may be hardly any symptoms at all, or perhaps general delicacy 
or ill-health, or gastro-intestinal disturbance, without any special urinary symptoms 
attracting notice. The urine generally contains only a trace of albumin, and no obvious 
]}us ; the diagnosis then depends upon bacteriological investigation of a catheter specimen, 
the need for which will be suggested by the discovery of a decided excess of leucocytes in 
the centrifugalized deposit from the specimen first collected during the routine examination 
of the patient. .Inn. Ejire. 

BALDNESS. — Alopecia, or baldness, may vary in degree from slight thinning to: 
complete loss of the hair. There are three main varieties of simple baldness or alopecia 
namely: (1) CoiigciiHal. (2) Senile, a.nd (3) Premature. 

Congenital Alopecia is seldom complete, and the hair may be laiuigo-like. In tin 
latter case the diagnosis is certain, as it also is when the baldness is accom])anied 1)\ 
developmental defects in the skin or its appendages. Wlien there is comjilete absence o 



BLACK SPECKS BEFORE THE EYES 71 

the hair, not only of the head but also of the eyelids, faee. trunk, armpits, and jiubie regions, 
tlie diagnosis is obvious. 

Senile Alopecia needs no description. 

Premature Alopecia may be (a) idiopathic or (b) symptomatic. The former, much less 
fre<|uent than tlie latter, and due to no recognizable cause except heredity, usually begins 
between the ages of twenty and thirty-five ; in many cases at the vertex, like senile baldness, 
but often at the teni])le, when it extends backwards elliptically. Symptomatic premature 
baldness may be either temporary or permanent, gradual or rapid, and is dependent upon a 
great variety of local or constitutional causes, including seborrhcea of the scalp, psoriasis, 
chronic eczema, erysipelas. ritigiLonn.favus. lupus, erythematosus, syphilis; it is also a sequela 
oi fevers or other acute systemic diseases, and sometimes of a severe shock to the nervous 
system such as inay result from a sudden and imexpected bereavement or the like. When 
it occurs as a sequel to fevers, in sjT)hilis, ringworm (except after severe kerion), erysi]3elas, 
and ec/.ema, the loss of hair is usually but tenijiorary : in seborrhcea, favus, lupus erythema- 
tosus, morplitta, and folliculitis decalvaiis, it is generally ])ermanent : it is always so when 
the hair-follicles have been destroyed. 

The most important form of symptomatic balilness is that which is associated with 
seborrliiea. whether of the oily or of the dry kind. Seborrluric alnprcia lias the same 
distribution as idiopathic baldness. Another form of symptomatic baldness is the condition 
known as alopecia areata, in which the hair falls out in more or less circular smooth white 
patches, generally of irregular distribution. I'sually the patches continue to spread for a 
time, and may run into others, denuded areas of irregular outline thus lieing formed, with 
a surface white and smooth as a billiard ball. The hairs at the edges of the patches are 
looser than the others, and among them may be seen short stinnps that have atrophied 
dose to the root, so that they resemble a note of exclamation (!). In rare cases the hair 
falls out not in patches but more generally and very rapidly ; and sooii the whole scalp 
may be bared, and even the hair of the whole body may be lost, and with it the nails of 
the lingers anrl toes. The affection with which alopecia areata is most easily confoimded 
is riui'icorui of llic trichophytic variety : the differential diagnosis between the two alTections 
will be found under hi xc.ors .\i'i-i;CTiONS OF nil; Skin (|j. 24fi). Alopecia areata may 
also be confused with another form of symptomatic bahlness, namely, alopecia cicatrisata, 
the pseudo-pelaite of Hroeq, in which depressed islands of baldness, round or of irregiilar 
shape, occur on the scalp, the |)atches usually spreading and coalescing into large, smooth, 
shiny areas : these are cicatricial : there is destruction of the follicles so that the hair is 
never restored ; there are normal-looking hairs on the bald areas, and the notc-of-exclama- 
tion stumps of alopecia areata are absent. The bald jiatchcs sometimes met with in 
secondary sy/jtiilis may be dislingiiishcd from those of alo]>ecia areata by the co-existence 
of oilier syphilitic symptoms, by the positive Wasscrmann's serum reaction, iind by the 
effects of s])ecific treatment. The bald areas of lupus erythematosus arc in greater or less 
degree cicatricial, there is destruction of the follicles, and a border which is slightly or 
distinctly inllanied. luillirulilis deadvinis is cii atricial also, and at the edge of the bare 
patches a small rc<l p^ipiilc (ii- p:ilc-|i oC cin (lii-iiia can he seen siirniiiiuling each follicle. 

Maliiitm .Monis. 

BEARFNG-DOWN PAIN. (Sec I'mn. Hi.aiun.^-im.w n. p. |-_'(1.) 

BLACK SPECKS BEFORE THE EYES arc of two ty|)cs : (1) Moving:. CJ) Fired. 

Moving Bhick Specks :iic |ii:i(lii;illy alwnys due to mused- I'olitantes. The aiiiicous 
and \il noils liiiiniiiirs an mil aiisoiiilcly homogeneous : in both there are minute particles 
in most persons, and llicsc throw sliadiMVs upon the retina which arc referred by the patient 
lo points in the visual held outside him. They seem to be in I'ronI of his eyes, interfering 
with what he wishes li> look ;il : \(l wlicii he tries lo liiciilr tlniii (IcHnilciv !iy looking 
directly at llicui, llic\ iininciihilclv llnal aw;i\-. as il were, IVoiii liis diiccl livid iif \ision 
to a peripheral part, lie can never locus llicm. aiidvcl he nia\ lieconscioiis of seeing them 
all the time. Only lew ))ersons in p<rlcct health are troubled in this way. for although 
the niiisea- Mililanles may be present all the lime, the mind neglects them and fails Lo 
notice them. When the eye is liicil by close work, however, or the patient is suffering 
from brain-fag. worry, insomiiia. Iiilioiisness or other similar condition. Ihey may attract 
his notice very much and make liiiii I'liir llial he is d<-\ clo|iing some serious lesion such 



72 



BLACK SPECKS BEFORE THE EYES 



as a cataract. JNIicroscopists often find them a great nuisance. After a rest or a holiday 
they will cease to obtrude themsehes upon the patienfs notice, but he will notice them 
again when he gets overworked or rim down. In a similar way muscoe volitantes may be 
troublesome in those who are suffering ill health due to almost any organic cause, especially 
if it is associated with AnvTsmia (p. 20). The way in which the specks float away when an 
attempt is made to focus them is characteristic. 

Fixed Black Specks. — When, on the other hand, the patient notices a black spot nr 
spots in liis field of vision, always present and always in exactly the same relationship 
to tlie jjoint upon wliich he is focussing his eye — not floating away into different parts of 
the held of vision like niusca? volitantes — a careful examination of the eye with the ophthal- 
moscope, assisted perhaps by the perimeter to map out the abnormal blind spot with 
accuracy, will generally reveal some organic lesion in the eye to aecoimt for them. An 
opacity in the cornea from old keralilis, or syneehise from adhesions due to old iritis, or 
a cataract, may be seen, or tiny white patches at the macula indicative of incipient albuiniti- 
uric retinitis of grave omen : or a small detachment of the retina ; or a melanotic sarcoma 
of the eyeball ; or early optic neuritis ; or a thrombosed retinal vein : or an embolizcd branch 
(if a retinal artery ; or a hcemorrhage into the vitreous ; or a scotoma from localized optic 
atrophy, such as is met with sometimes in cases of disseminated sclerosis. Special ophthal- 
mic experience will be needed to diagnose between these different conditions, althougii 
the ophthalmoscopic a|)pearances (p. 41.5) of some of them are pathognomonic. 

Herbert French. 

BLEEDING GUMS. — -^ spongy, bleeding condition of the gums, attaining such a 
degree that the teeth become covered by the exuberant blood-oozing tissues, was a 
prominent feature of scurvy, a serious and often fatal disease which used to be common 
on sailing ships when fresh food was necessarily absent from the diet for weeks or even 
months at a time. It is now rare in its full development, but is still foimd in a mild form 
amongst children — infantile scurvy, or Barlow's disease — as the result of long-continued 
feeding with tinned milk without fresh food. Its chief features are anscmia and tenderness 
of the long bones due to ha-morrhagcs under the periosteum ; in severer cases, besides 
sponginess and bleeding of the gum with more or less general stomatitis, there maj- be 
purpura and other ha>morihages. The diagnosis is suggested by the diet history, and 
confirmed by the benefit that follows the addition of fresh milk and. in older children, 
fresh vegetables. A similar condition may arise in adults whose circumstances compel them 
to live on tinned foods. There are, however, many other causes of bleeding of the gums 
besides scurvy. The differential diagnosis is generally easy, but sometimes very dilTicult. 
The first point to determine is whether the gum condition is due to local changes only, or 
whether it is part of a more general condition. 

(.1). Bleeding Gums due to General Conditions or preceded by Lesions else- 
where than in the Mouth : — 



Scurvy 

Splciionicdiillary leuk.'emia 
Lympliatic IciiUu'iniu 
Hodykiii'N disease 
Perniciiius aiianiia 
Aplastic auiemia 
Splenic ana-mia 
Harnophilia 

(B). Bleeding Gums due 

Injury, e.g., by toutli bnisli 

Dental caries 

Tartar 

Pyorrhoea alveolaris 

Alveolar abscess 

Pa])illonia 

Epulis 

Myeloid saroonia 



Purpiua (see Pl'rpi'R.\, p. o.32) 

Syphilis 

Mercurialism 

Iodide poisoning 

Phosphorus poisoning 

Arsenic poisoning 

Lead poisoning 

to purely Local Conditions :- 

Epithelioma 
Actinomycosis 

Acute or chronic stomatitis 
not obviously due to any of 
the causes already men- 
tioned, e.g. : 

Aphthous stomatitis 
T_'leerativc stomatitis 



Febrile or asthenic states 
accompanied by sordes, e.g., 
pneumonia, ty]ilioiil fever, 
the later stages ol' nialiyiuiiit 
cachexia, general paralysis, 
acute yellow atrophy ol' tlie 
liver, and so forth 

Dyspepsia 



Gannrenous stomatitis 

(cancrum oris, phage- 

da;na oris, noma oris) 

Tuberculous gingivitis 

Erythema bullosxim, dermatitis 

herpetiformis, |)empliia;us, 

affecting the mouth as well 

as the epidermis 



A. Bleeding Gums due to General Conditions. — iMan\- of the above conditions arc 
discussed under other and more prominent symptoms, so that here we need refer to them 
but briefly (see Spleen, Enl.\rgement of, p. 628; An^mi.\, p. 20 ; Purpura, p. 552; etc.). 







BLEEDING GUMS 73 

A blood-eount is required to diagnose or exclude letikwmia or pernicious ancemia. Tlie 
family history may suggest hcemophilia. Splenic anwmia, Ilodgkin's disease, and aplastic 
anamia attract attention more on account of the enlargement of the sjjleen (p. 628), 
or of the lymphatic glands (p. 376)^ or of the ana?mia (p. 20), than because of spongy 
gums. Purpura (p. 552) is itself a symptom and not a disease. 

Syphilis, particularly in its secondary stage, may produce stomatitis, pharyngitis, 
lar>-ngitis, and gingivitis, with bleeding, even when no mercurial treatment has been 
adopted ; the secondarj' roseola may still be present, or the history may be obvious. 
Dilliculty arises mainly in women and children, and when the chancre has been extragenital 
(Fig. 23). ^Vasse^nlann■s serinn 
test may be tried, or the Spiro- f 
clmta pallida (Plate XXVIII, 
Fig. J. p. (il4) looked for in scrap- 
ings from the mucous lesions. 

Mercury is very liable to 
cause profuse salivation and acute ^^^^B ^^^Wmi^^' ? 

stomatitis, with distressing and ^ ^ . _ 

painful swelling of lips, gums, 
tongue, and cheeks : swallowing 

may become impossible, the glairy ^,V,. ^S.-PrUnary syplulitic soie on ti.e lower li|.. 

saliva hangs in strings from the 

protruding tongue and bulging lips, the mucosa bleeds on the slightest touch, and tlie 
patient is the picture of abject misery. Some persons are far more intolerant of mercury 
than others, but its worst effects have occurred when the remedy has been employed when 
the teeth arc carious, or the mouth unclean, and when there is albuminuria (syi)hilitic 
nephritis). The diagnosis depends upon a knowledge of the drugs that are being given 
or. in occupation cases, of the chemicals that the patient has been working with. 

Iodides may cause profuse coryza, due to conjuncti\al, nasal, and oral catarrh, but 
the amount of bleeding that accompanies it is slight. The nature of the drugs being taken 
will suggest the diagnosis, or if there is doubt as to the drugs, the urine may be tested for 
iodides. 

Phosphorus used to produce very severe stomatitis, going on to necrosis of the jaw — 
• pliossy jaw ■ — not infre<|uently ending in death as the result of fatty degeneration of 
the li^■er antl heart : this is unconnnon since restrictions have been laid upon the use of 
crude yellow ])ho.sphorus in the manufacture of matches. The oecu])ation generally serves 
to suggest the diagnosis. fc^Kp t*' 

Arsciiir and lead are both rare causes oT hlii-ding gums ; (ic( iipalioii. or medical 
l)r(seriptioii, or habits as regards drinking, may suggest the diagnosis, and there may be 
other signs of the |)oisoning, particularly |)igmentation of the skin, vomiting, diarrhd'a, 
hyperkeratosis of the soles and palms, and generalized i)erii)heral neuritis in the ease of 
arsenic' ; and the symptoms given elsewhere (p. :; t) in the case of lead. Arsenic may be 
found in excess in the hair, or lead may be detected in the faces or in llu- lesidue from a 
bulk of urine. 

Febrile' nnd asthenic states only cause sordes and bleeding gmns when the i)atienl has 
already been ill some while, or wlu'ii the nursing has been remiss ; the diagnosis will depend 
on syniptoins other than those comiected with the gums. 

H. Bleeding Gums due to Local Conditions. Wlmi eai( has been laktii lo exclude 
Ijeiieral causes of bleeding of (he giuns, (liHei'enl iai ion between the ^■arioUs local causes is 
nf)t diiri<ull. Some patients are alarmed l)\ tlie sym|)lorn. when its cause is nothing more 
than the use of a nr:v litolh-hrusli whose bristles have slightly lacerated gums tliat are 
accustomed lo an older and softer brush. The history will indicate other liirms ol local 
injury ini ill-lilling loolh-plate, pcrhajis. Ihemoptysis may be simulated. 

Dental caries may be obvious, or it may be hidden away I)et\veen arljacent teeth and 
yet be irritating the gum enough to cause it to bleed with undue readiness when the teeth 
are brushed. Tartar is obvious on inspection. I'yorrhira ahealaris. also known as 
suppurative ginaivitis or liigg's disease, is the n'suK of septic iid'cetion exieniling down into 
the sockets, loosening the teelh. causing Ihc guni Ttiari;ins lo recede bv erosion, and leading 
to a pinuleiil liiseliarMe Iniiii lielween llie ^niins :iihI Die teelh. 'I'liis <'oM(lilion mav be 



BLEEDING (iUMS 



present even when the external aspeet of the teeth seems perfect ; a very fine probe may 
.sometimes be jjassed painlessly down into the tooth-socket between adjacent teeth where 
the suppurative process has been progressing unsuspected, and out of the reach of the 
tooth-brush. The gums bleed on the slightest touch in severe eases, the breath is foul, and 
the constant swallowing of pyogenic organisms and their products leads to dyspepsia, 
ana"mia, chronic ill health, listlessness, functional nerve disorders, and sometimes more 
acute sym]itoms of general pyaemia, especially multiple infective synovitis and arthritis. 
Neurasthenia and depression ultimately ensue in many cases, and sometimes very severe 
and even fatal ancemia or purpura. 

The diagnosis of alveolar abscess is generally obvious, though infection of a benign or 
malignant neic groivlh may simulate it for a time. Microscope examination of the excised 
tumour is the only certain way of diagnosing the nature of an odontoma, papilloma, simple 
epulis, myeloid sarcomatous epulis, or epithelioma of the gum. 

Actinomijcosis is rare in man : but the jaw, gum, or cheek are parts least imcommonly 
affected. The chronic nature of that which partakes of the characters partly of a neoplasm 
and partly of an abscess, in a person who has had occasion to put straws, cotton, or other 
vegetable products into his mouth, may suggest the diagnosis, which will be confirmed by 
the iinding of the ray fungi in the purulent discharge, or in sections from parts excised. 

Minute grey or yellowish specks in the pus are 
said to be characteristic, but they are not always 
seen, and it is by microscopical examination that 
the diagnosis is made with certainty (see Plate 
XXl'III. Fig. S. p, 014). 

Stomatitis in its various degrees may have a 
general cause, such as mercurialism (see above) : 
or it may be due to purely local infection with 
micro-organisms. It might perhaps be classifitd 
bacteriologically — the variety spoken of as thrush 
being due to the oidiam albicans, for instance, 
t'linically, however, it is more often classified by 
its degree — into acute catarrhal, ulcerative, and 
gangrenous. All these affect the mucosa of 
cheeks, lips, tongue, and palate, in addition to 
the gums, and any of the inflamed parts bleed 
readily. The first degree is characterized by red- 
ness, swelling, tenderness, and pain, with inability 
to move the tongue about in order to eat and 
swallow, swelling and jirotrusion of the lips, foul- 
ness of the breath, and very often salivation. 
There may or may not be localized greyish or 
white aphthous patches ; these are commoner in 
children. When ulcers occur, these are generally 
nuiltiple and shallow, very painful, with more or less glazing of the ulcerated surface, 
and acute hy])cr!iemia of the margins. The gangrenous form is better known as caiicrnm 
oris (Fig. 24), fortunately rare, though sometimes seen in ill-eared-for children who have 
contracted measles or some other acute (Iil)ilil:iting fever. The cheek is affected first, a 
dusky-red or black spot appearing within and without, spreading rapidly and leading to 
sloughing and perforation of the cheek, gangrene of the gums and jaw, falling out of the 
teeth, a very foul nauseating odour of the breath, and death from utter exhaustion. The 
diagnosis is generally olivious. 

Tnbcrcalinis gingivitis is rare, but when it does occur it is very severe. The natm'c 
of the bleeding gums will be suggested by the co-existence of phthisis, and tubercle bacilli 
may aboimd in smears from the gum. 

Erythema bullosum. dermatitis herpetiformis, and pemphigus — particularly the first — may 
affect mucous membranes as well as the skin, especially the mouth, colon, and vagina. 
The result as regards the mouth is very distressing ; the crusts and resultant inflammation 
of lips, gums, tongue, cheeks, palate, fauces, and jiharynx, may make it impossible for food 
to be taken orally, and the ])atient loses weight rapidly and Ijeeonies very ill. The nuieous 




Fhj. --M.— Cai 



BLOOD PER ANUM 75 

membrane everywhere bleeds on the shghtest touch, and the condition is pitiable. There 
is generally pjTcxia. The diagnosis is. as a rule, easy, for the mucous membranes are 
seldom attacked unless the skin is affected also (see Bullae, p. 86 and Ecsinopiiilia, 
p. -18). Herbert French. 

BLEEDING NOSE. -(.See Epistaxis, p. 220.) 

BLEEDING, UTERINE. — (See Menorrhagia, [). 385 ; Metrorrii.vgia, p. 380 ; and 
Metrostaxis. ]). 392.) 

BLINDNESS.— (See Vision, Defects of, p. 7.57.) 

BLISTERS.— (See Bri.i,.T;, p. 96.) 

BLOOD, COUGHING UP OF.— (See H emoptysis, p. 28.5.) 

BLOOD IN THE URINE. -(See Hematuria, p. 275.) 

BLOOD PER ANUM. — Blood may be passed i)cr anum whenever bleeding takes 
place from any part of the alimentary canal. If it comes from a point high up, as from 
the stomach or duodenum, it is usually altered in appearance, so that black, tarry stools 
arc passed (mchena) : if it comes from the colon or from the lower end of the ileum, it' is 
passed as red blood, easily recognizable as such. If the (|uantity is xcry large it may be 
bright red even in the case of lesions high-up : the colour ikpcnds on the rapidity of jmssage 
through the Ixiwel and the eonseijuent extent to which the digestive juices have acted 
upon it. 

Bccognilion of the actual presence of blood, pure or mixed with the motions, is not 
(iltcii dillicull, except when the (piantity is small. The typical tarry stools of hiemorrhage 
high up in the alimentary tract arc unlike anything else. The black colour is much more 
pronounced than the pigmentation of the stools caused by iron or bismuth sulphide, which 
produce rather a slaty or dirty greyish-black tint : while the viscid consistency of the 
ha-niorrhagie stool is also characteristic. Administration of charcoal by the mouth may 
produce deep black stools, and eating bilberries is also said to do so. In case of doubt, 
the chcmiea! aiwl spcctniscopieal tests for l)lood may be applied : for which purpose it is 
best to aeiduiiili- tlic faces strongly with acetic acid and to extract the acid mixture with 
ether : a clear solution of blood-pigment is thus obtained, suitable for the spectroscope 
or for the guaiacum test. In some cases blood corpuscles may be recognizable imder the 
iiiicroseope if a portion of the fa-ces is rubbed up with physiological saline solution, (irains 
ol charcoal will be distinguishable under the microscope if this substance has been taken. 

Tlic conditions associated willi the passage o! blood pvv anum may be divided con- 
veniently for diagnostic purpose into : (1) 'I'Iidhv in n'liich lrir«c <iii<inlitiex of nllerc/l hUuid 
are ptisseil (true niehena) : (2) I'hosr in ■u'liich liir<ir ijniinlitir.s of red or inidllcrcil blood (ire 
voided; (3) 'Dntse in icliicli sniidl amoniils <if such hlooil ore seen ; and ( t) Coses of so-v(dled 
oieiill liifniorrlnitie, only recognizable by chemical or <>tli(r special tests. The conditions 
eliissed under hcailings (2) and (3) necessarily overlap, inasniiich as the exact ciuantity of 
lilcHiil (lis<1iMigiil is \(ry \ariMl)le: the lormcr comprise, roughly speaking, alieeliims of 
the liciwcl ; llir Nillci-, lesions iilioul the icctutii and anus. 

Large quantities of altered blood mny escape in cases of ulceration ol' the slomaeli 
or duodenum. It is usually mixed with acid gastric juice, and thus blackened. .Such cases 
are g<'nerally associated with |)ain after meals, vomiting, lia'inatemcsis, and increased acidity 
of the gastri<' juice. Tenderness will be elicited on pressure over the epigastrium, most 
often at a point rather to llu' right of the middle line and about four inches below the 
xiphisternal jimetioii in the pyloric region. Distinction between lesions of the stomach 
:iii(l 1)1' the duodenum is dillieult ; l)ul in gastric ulceration the pain usually arises within 
:ni Ininr after meals, and is relieved by vomiting : in duodenal ulcer, it often reaches its 
a( me iilxiul Ihiic or lour hours after a meal, aixl II may .it lirsl be relieved by taking food 
(• huiiMcr pMJii). Ill gastric ulcer, the greater part of llic blood which escapes is likel> 
lo l)c Miinilccl : ill diiodeiial. most of it to be passed per aiiiim. Duodenal uleeration is 
iniisl eoiiimoii in men. 'I'lii' symptoms of gastric ulcer are much more <-oiiiiiioii in women : 
but it has been shown that in many such instances no actual ulcer can be found, the blood 



76 BLOOD TEK ANUM 

escaping apparently by a process of oozing through the mucous membrane — a condition 
referred to as gastrostaxis. Evidence obtained fi'om post-mortem findings shows the two 
sexes to be about equally liable to this affection. 

Large quantities of unaltered or but slightly altered blood may be passed in cases of 
ulceration of tlie small intestine, as in enteric fever, tuberculosis, or the peculiar lesions 
associated with chronic interstitial n('i)liritis. The jihenomena of enteric fever need not 
be detailed at length — initial luadaclic, cpistaxis, and fever ; fullness of the abdomen and 
possibly diarrhoja, rose spots, enhngenunt of the spleen, mental dullness or deliriuni : 
leucopenia, and Widal's agglutinative reaction in the blood. Tuberculous ulceration of 
the intestine seldom, if ever, occurs apart from tuberculosis of the lungs, and it is a rare 
cause of profuse intestinal hsemorrhage. It is associated with pain and tenderness in the 
abdomen, and with emaciation and signs of pulmonary disease. Tubercle bacilli may be 
foimd on examination of the faeces. 

Chronic Brigltt's disease may be associated with ha?morrhage from the bowel as from 
other parts of the body. The absence of other causes, such as ulceration : the existence of 
liigh blood-pressure and enlargement of the left ventricle, the cardiac impulse being dis- 
placed outwards and downwards ; and the constant or occasional appearance of albumin 
and renal tube casts in the lu-ine, with weakness, antemia, and perhaps epistaxis, will point 
to this cause. 

Bleeding into the pancreas and eniljolism or thrombosis of one of the mesenteric vessels 
may both lead to moderate haemorrhage from the bowel. In both alike there will be 
symptoms of sudden abdominal pain and constipation with collapse, closely resembling 
the phenomena of intestinal obstruction. A certain diagnosis can hardly be made without 
laparotomy. Patients who sidfer from pancreatic apoplexy are usually fat. Blocking 
of a mesenteric vessel by embolism is most likely to occur in sufferers from some form of 
cardiac disease, especially malignant or ulcerative endocarditis (p. 34). 

In the peculiar condition known as HenocKs purpura (p. .556) there occur attacks of 
colic, constipation and vomiting, with passage of blood per anuni. The symptoms may 
closely simulate intestinal obstruction or intussusception, and may be indistinguishable from 
mesenteric embolism. A diagnosis may sometimes be made when other phenomena of 
bleeding are present, such as hsematemesis, haematuria, petechia: in the skin, or cpistaxis. 
or by concomitant affections of joints (hEemorrhagic arthritis) : the patient is generally 
yoimg ; a history of previous attacks may also be obtained. 

A good deal of blood may be passed per anum in some cases of general lia'morrhagic 
conditions, such as profound anaemia, leuka?mia, and purpura ha;morrhagica. The general 
appearance of the patient, and examination of the blood (p. 24) w-ill suffice to distinguish 
the two former ; and in the last there will j)robably be visible haemorrhages in the skin 
and bleeding from other mucous surfaces. 

The possibility of the rupture of an aneurysm into the stomach or bowel may be men- 
tioned for the sake of completeness ; a diagnosis can only be made by recognition of the 
]>ulsating aneurysmal swelling, and the condition will probably be rapidly fatal. 

In infants, considerable quantities of blood may be passed per anum owing to septic 
infection of the umbilical cord, the ha>morrhage arising either from an actual ulcer of the 
stomach or duodenum, or from a purpuric condition caused by bacterial toxaemia ; in a 
few such cases running a rapidly fatal course the passage of dark or bright blood per rectum 
in increasing quantities is almost the only symptom, and the cause of the bleeding is not 
clear even when searched for at autojisy ; the fatal symptom may develop within a day 
or two of birth (Mcla-na neonatorum). 

Haemorrhage of moderate degree is usually associated with disease of the large 
intestine, though occasionally profuse bleeding may occur in such affections. The blood 
is bright in colour and generally mixed with mucus. In tropical dysentery there is severe 
tenesmus and great frequency of deficcation, only blood-stained mucus in small quantities 
being passed wlien the disease is well established. In ulcerative colitis, which appears to 
be a bacillary dysentery of temperate climates, there are the same diarrhoea, frequency 
of defaccation, and wasting as characterize the tropical malady, but tenesmus is less marked 
and the stools are usually more faecal. Some cases of idcerative colitis closely simulate 
enteric fever ; they may be distinguished by the absence of Widal's reaction, and by recog- 
nition of the idcers in the lower part of the large bowel by means of the sigmoidoscope. 




oc 



BLOOD PER ANUM 77 

Examination of the stools in cases of tropical dysentery may reveal the presence of 
the AmKha histolytica (Fig. 25). This large organism measures some 30 to 40 /, in diameter 
and is distinguished from the harmless Amoeba coli by its well-developed clear outer layer 
of ectoplasm, by its small and eccentrically placed nucleus, and by the presence of inoested 
blood-corpuscles within its substance. " "^ 

In the search for amceba; a flake of mucus should be spread out as thinly as possible 
on a slide, and if the organisms are very scanty, the addition of a drop of 1 per cent watery 
methylene blue is of assistance, as it stains the pus and epithelial cells at once, whilst for 
a time the amoebiB resist taking up the stain and also retain their activity : they'thus stand 
out clearly amid their blue surroundings as light refraetile motile bodies. In such a pre- 
paration examined directly after it is made, it is possible to detect them with a very low 
power, such as a Zeiss A or a half-inch lens, a higher power being turned on to verify the 
find. ^Vith some practice they may also be seen in unstained mucus with the low power 
as small glistening particles, the condenser being fully lowered for this method of examina- 
tion, and any likely object being scrutinized further by a i inch lens. Full doses of 
ipecacuanha or emetine should not be given before the stools are examined microscopically 
or a negative result is likely to be obtained in amoebic cases, just as in malaria after quinine 
has been taken. The stools should 

always be examined as fresh as ^ 

possible, preferably within an hour 
of being passed. In cool climates the 
specimen may be kept at blood-heat 
for a short time and the slide warmed. 
The organisms •-hould always be seen 
in active motion before a positive 
diagnosis is made, for there arc often 
large mucoid cells present, especially 
in bacillary dysentery, which may 
easily be mistaken by the inexperi- 
enced for inactive ama?ba;. 

In bacillary dysenterj' the patho- 
genic organisms belong to a group of 
closely allied bacteria classed under 
the title B. di/senterice. They are 
short, rod - shaped bacteria, with 
rounded ends, somewhat resembling 
II. inpliii.'iiis, but uon-iiKitile. These 
haeilll grow on ordinary laboratory 
media, do not coagulate milk, and do 
not form indol. They are not stained by (iram": 
ulcerative colitis is undetermined, but organisms 
isolated by some observer.s. 

Malignant dincasc of the intrslinr may ylvc rise t 
typical case'of cancer of the large bowel, an cldcrlv person has sullered from ..radually 
increasing weakness, wasting, and constipation. .Utacks of colicky i«iin may supervene, 
and some enlargement of the abdomen may be noticed. Blood mav be present in the 
motions from time to time, hut is not often a marked feature. Examination of the 
abdomen may reveal \ermicular movements of the hvpertrophied bowel, which tend to 
pass m a d,H,„|,. ,lin<li.,ii along the course of the colon, an.l to cease at a particular point. 
Here a .lehmte tumour may be palpable ; but as the llexures of the colon are lavouritc 
seats for neoplasms, it often happens that the growth is situated deepiv in the pelvis or 
beneath the lower ribs, and cannot be felt. There is little or no IcN-er unUss there arc 
extensive secondary deposits, especially in I he li\,r, which mav become greatly enlarged. 
Acute inteslmal obstruction may finally occur. The diagnosis is often assisted either bv 
the sigmoidoscope' or by the use of ,r-rays alter a bismuth meal (p. ]•_'.-,). 

As contrasted with the above, non-malianaiil iilnmlion of tlir niloii is likcK |,, i,avc 
a more marked ons.l. with pain. Irc,,uencv ..I .Idacaliou, an.l loose n.oli.ms Th.- stools 
often eonlain eonsi,|,.n,l,|,. ,,uarililirs ol blood mixed will, mucus. The bo.ly U-mperalure 




Fig. 25.— foo Ama-ba histolytica faftcr Jilrgciis); f6) Atimba coli. 
/"v? V " ' (b')^Amaba mli, encysted (after ClwaaraiKli and linrbusallo;. 



(N) Nucleus ; (N') Kuck-i alter div 
pintvr.) 



melhod. The 
reseml)linij li. 



. (C) Wood corpi 

exact bacteriology of 
ili/snilrii(e liave been 

>r hu'inorrhage. In a 



78 BLOOD PER ANUM 

is raised, often to a high degree (103° F.)' pa'" is "^ore constant, and tenderness may be 
elicited all along the course of the large intestine. Often the ulceration extends into the 
sigmoid flexure of the colon, and may be visible on examination with the sigmoidoscope. 
In ititussusceplion, blood and mucus are passed without ftecal matter accompanying 
them. The condition is commonest in infants and young children. There are usually 
symptoms of severe illness, with screaming, drawing up of the legs, frequent pulse, and 
some collapse ; rarely the condition may be encountered with but few grave signs. A 
rectal examination is essential, as in many cases the intussusceptum may be felt with the 
finger ; a careful palpation of the abdomen will usually reveal an elongated tumour, which 
may sometimes be felt to harden and relax again with the peristalsis of the gut. 

In infants, simple colitis may give rise to the appearance of blood and mucus in the 
motions, but there is generally some fa?cal material passed at the same time, which is not 
the case in intussusception after the contents of the colon below the intussusception have 
been evacuated. In simple colitis the motions are frequent and loose, and they may contain 
nuicus. In milder cases they may be green and slimy, but in the more severe they are 
brownish and verv offenst\'e, iind in the worst cases consist of little more than a dirty serous 
discharge. The child's temperature will probably be raised ; the pulse is frequent, and 
there nfay be vomiting. A collapsed condition may occur at a late period of this malady— 
rarely, in acute choleraic cases, it may ensue within the first twenty-four hours. In intussus- 
ception, on the other hand, collapse usually occurs quickly : and there is absolute con- 
stipation, with iiassage only of a small amount of blood-stained mucus. The only cases 
which can give rise to a dilliculty of diagnosis are the rare instances in which intussusception 
is ]5resent without severe symptoms ; and here rectal and abdominal examination will 
probably reveal the true condition of affairs. By means of rectal examination in an infant 
a considerable area of the abdomen can be investigated, especially if an anaesthetic be 
administered. In all cases of doubt in intestinal affections accompanied by bleeding this 
procedure is urgently demanded. 

The intense diarrhea accompanying arsenical poiso/tiitg may be accompanied by the 
passage of traces of blood and mucus. The condition will be distinguished by its rapid 
onsetrsome half-hour, or so after a meal, by the epigastric pain, tenderness, and vomiting, 
followed by collapse, jvith rapid irregular pulse, and clammy skin. A chemical examination 
of the vomited matters should be made in suspected cases, by Keinsch's or Marsh's test. 

Traces of blood smeared over the motions are suggestive of piles, which may be seen 
on inspecticni if external, and felt by the examining finger if internal to the sphincter. 
Occasionally a sharp attack of bleeding may occur from this cause if a varix be ruptured. 
The condition is usually accompanied by a sense of fullness, weight, and even pain in the 
rectum, and the patient may be conscious of " something coming down " and having to 
be replaced after defa?cation. 

Some amount of blood may arise from an anal fistula, which may also lead to a dis- 
cluirge of mucus and of pus. Inspection and digital examination will discover this 
affection, the external opening of the fistula being close to the margin of the anus, the 
internal often just above the border of the sphincter. 

Cancer of the rectum does not usually give rise to much haemorrhage, but traces of blood j 
may be passed from time to time, and sometimes a sanious discharge occurs. The main i 
syniptoms are usually wasting and cachexia ; gradually increasing difficulty in defalcation : 
and rarely, aheratioii in the size and shape of the fa?cal masses, which may be thin or ribbon- 
like. Sometimes alternating periods of diarrhoea and constipation occur : or there may ^ 
be morning diarrhoea, the matter passed being thin fluid. Pain in the sacral region generally ] 
occurs at some period of the disease, and it may radiate down the thighs. The growth may 
l)e seen by means of the speculum or sigmoidoscope, and also felt by the examining finger. 
Reeiul poljjpi are common in ihildren, and may rarely be encountered in adults. They 
give rise to frequent bleeding, which may occasionally be considerable in amount. The 
patient may be conscious of something present in the rectum giving rise to a sensation 
of fullness and frequent desire to defalcate. Digital examination will reveal the existence 
of a pedunculated tumour, or rarely of multiple tumours. Occasionally a polypus may 
protrude at the anus after defa-cation. and nnist be <listinguished from prolapse of mucous 
membrane by examination with the finger. 

Another condition affecting the rectum which may be signalizetl by free bleeding is 



BLOOD PER ANUM 



79 




Fig. 26.— Ova of BiUmrzla Imiilaliihi 
tr a terminal -spine — the common form ; t 
■eseiiting a lateral spine. (Uuilt poirtr.) 




that of papilloma or villous tumour. The symptoms will closely resemble those of rectal 
polypi, but the blood is likely to appear in large quantities. Digital examination may 
discover a soft, velvety patcli on the rectal wall, and the examining finger will be with- 
drawn covered with blood. The growth may be seen by means of a specidum as a soft, 
vascular ma.ss, bleeding on the slightest touch. The condition is miconniion. It is likely 
to occur at an earlier age than cancer, but the latter is not unknown in persons under 20 
years of age. 

Simple prolapse of Hie anal mucosa will lead 
to slight ha-morrhage. The condition is often 
seen in children, and may be recognized on in- 
spection of the anus, when a red globular swell- 
ing of everted mucous membrane is visible. 
Adults will be conscious of having to push the 
part back after passing a motion. Such prolapse 
often acconi])anies piles. 

i'lccralioii of the reetum. of venereal origin, 
occurs chiefly in women. Bleeding is not usually 
a very marketl feature, but attacks of haemor- 
rhage may take place. The condition is recogniz- 
able by digital examination, and by inspection 
through a rectal speculum or the sigmoidoscope. 

Tlie ulceration usually extends right down to the anus, whereas there is nearly always an 
intiival of normal mucosa between the anus and an ulcerating cancer of the rectum. 

'J'lie |)arasite called liilhartia Jurmatobia may occur in the rectum, though less 
fr((|uently here than in the bladder. Its presence gives rise to the passage of mucus 
and blood per anuni. There may be discomfort in the rectum and frequency of defaeca- 
tion. Infection is contracted abroad, especially in Kgy})t — a fact which may lead to a 

suspicion of the presence of the affection in patients 
who have resided out of I'^ngland. Diagnosis can 
only be made by finding the ova of the parasite in 
the fa'ces. Their well-known shape — oval with a 
pointed spike at one end, or rarely at the side {Fig- 
2(i) — renders them unmistakaljle objects under the 
niieroseope. 

In eliildicn I lie |ircs(iiee of I liicad-worms (Oj'J/- 
uris vcrmicuhirin) in the rccliiin Mia_\- lead to tlie 
liiscliarge iil small ainoimls ol mucus coloured by a 
liacc ol bliiiid. 'I'lir wiirnis will be seen readily on 
inspection of the child's motiims. They are white, 
about the thickness of coarse lliicMd. and \ to j in. 
in length. 

In some cases the actual cause of even much 
blooil being passed per anum remains luidiagnosable, 
and (iccasioii Hl\ llic cause seems to be 'vicarious 
nil list lual inn,' nol u il listanding the doubts held by 
mari\- as Id llie i)(issil)ility n[ the latter. The follow- 
ing is a very suggest ive case from the ))ractiee of 
Dr. Keuell AtUins.m : "A girl, age i:U, very tall (or 
her age, menstruated regidarly for more than a year. 
T was sent Cor because she was jiassing blood per 
aiuun : that was on A|)ril !». The blood was (piite 
l)riglil and In ((iiisidciMlilc (|u:uilil\ ; I here was no oilier syni|il(>m except a little nausea 
and voniitiiig of fiolhy mueiis. She complained of pain, mostly over the pubes on each 
evacuation, but none at other times. No abdoinimd tenderness or distention. No tem- 
perature. Nothing to be r<-!t per rec'tum. On .Vpril 1 !■ she passed a large dark, semi- 
digestc><l clot. About the 'Jlth she ought to have menstruated and <lid not. The blood 
continued to be passed until the "iSth. Just a trace on the 'iittli. None since. She has 
remained well, mcnshuiilinn has recurred regulailv, and llicn' has been no repetition of 




Fifj. 27. — AukiilnsUtmujit dttotlemilr. A. 
wllh liooks; B.'i'nil; c. Kntire worm. 
liiticrr). 

(l-'rom Mnliml hai>nralory Methods. 
Dr. Horhert l''i 



lle.1,1 
(h.w 



BLOOD PER ANUM 









^j 



'1 






^-^ 



•S^ 












Fig. 2S.—dnkijlos[u)iu(m duodcnalc. Ova at different 
stages. Near the centre is an ovum of Trichocephalus dispar 
(x 50). (By permission, from Dr. Haldane and Dr. Boycott's 
paper in The Journal of Hygiene, Vol. iii.) 









^h 



w 







f.K 



Fig. 29. — .Inh-i/lostoiiiiim fhuuhiifilf. Two-cell stage of 
deveioping o\Tani (x 200). (By permission, from Dr. Haldane 
and Dr. Boycott's paper in The Journal of Hygietle, Vol. iii.) 



SPECTRAL .VESOKPTION BA2;DS. 



I 


II 1^ 




■ 


M ^H 




Fi, U — I.i luced lj-.i-iiL,.L'l(.l.iri. 


1 


ir -^m 




I 


T :^^m 




W ^^^I^^^^H 


I'l'i. :;l.— Acid haimatin. 


1 ■■^■■i 


Fig. ;^5. — Hethiemoglobin. 


1 


■ ^^B 



BLOOD-PRESSURE, ABNORMAL 81 

the passage of blood per rectum, and she seems to be a normal girl. What was the 
cause of the bleeding, and wliere did it come from ? ^^'as it an instance of vicarious 
menstruation ? "" 

Occult haemorrhage is the term applied to the presence of minute traces of blood 
in the motions, revealed only by chemical or spectroscopical examination. It may occur 
in any lesion of the alimentary canal in which there is breach of surface, as in ulcer, cancer, 
or .severe inflammation. Such hicmorrhage will also be present constantly in cases of 
infection with the parasitic worm Ankijlostomum duodenale (Fig. 27). This condition, 
which is met witli in persons who have resided in certain parts of the tropics such as India, 
or who have worked in mines or tunnels in which the soil has been contaminated by fellow- 
workers suffering fiom the disease, leads to profound ansemia ; and tlie ova of the worms 
may be found in the fieces by microscopical examination (Figs. 28 and 29). The tests for 
occult bleeding may be applied in cases of difficulty when there is reason to suspect ulcera- 
tion or cancer. No meat or meat-extracts must be administered for a day or two before 
the test is made, lest the haemoglobin present in them sliould vitiate the results. The 
existence of any bleeding from the gums must also be excluded. One of the simplest 
methods of detecting occult hicmorrhage is to rub up some of the faeces with water, acidify 
with strong acetic acid, and then shake out with about I volume of ether ; the latter 
extracts the hffimatin, and the characteristic bands may be detected in the ethereal extract 
by means of the spectroscope (see Figs. 33 and 34). w. Cecil Bosanquet. 

BLOOD, VOMITING OF.— (See H.«matemesis. p. 26.-,.) 

BLOOD-PRESSURE, ABNORMAL. — Blood-pressure cannot be gauged accurately 
with the finger : when instruments of jjrecision are used to verify opinions expressed as 
the result of merely feeling the pulse, it is astounding how erroneous digital impressions of 
pulse-tension and Ijlood-pressure are. It is most important not to diagnose an abnormality 
of blood-pressure until the latter has been measured instrumentally. There are four main 
kinds of blood-pressure, namely, maximum systemic arterial ; minimum arterial ; mean 
arterial : and venous. Instruments have been devised for measuring all these, but clinic- 
ally the only really important variety is the maximum systemic arterial lilood-pressure. 
This may be either iiljiiormalli/ /oic or filjiioi/iiiilli/ liigli. but no stress should he put upon any 
but considerable departures from the normal. Healthy individuals who have not been 
kept in bed have an average pressure in early adult life of 120 to 130 nnu. Ilg. Children 
have less than this, though at this early age it seldom hai)pens that anything is to be learned 
by measiu-ing the blood-pressure. .As years advance, the blood-pressure tends normally to 
rise, so that at fitly or si\ty a reading of 1.50 or 100 nun, Ilg, or thereabouts, which in a 
younijer person would indicate disease, would be normal. 

Abnormally high blood-pressure may reach figures such as 320 mm. Ilg, and any- 
thing from 170 mm. Ilg upwards is essentially abnormal, whatever the age of the patient. 
It nearly alwa>s indicates rigi<lity of the vessels as the result of arteriosclerosis, and it is 
very olten assoeialcd with renal <legeiiernlion, which, as time goes on, ultimately becomes 
red granular contracted kidney. Curiously enough, and contrary to what might be expected, 
the maxinunn syslolie blood-pressure is higher than normal in eases of luarl luilure such as 
result from inilnil stenosis, even when the i)ulse is so irregular and fe(l)lc that i( can only be 
felt with certain beats, and when one would have thought that there nmst be a fall in the 
hlood-pressure : the cause for the rise in such eases is prol)al)ly the piirtial aspliy.ria acting 
upon the \Msoinolor eeiitrt' : similarly, a rise of l)loo<l-pi(ssure. e\cn lo 220 mm. Ilg or 
more, may accoiiipaMV Hie aspljyxial attacks of I{ayri;iiid"s syndrome. Cases of meltiiiehnliii 
have al)norm;i||y high blood-pressures : when the melancholia improves, the pressure falls, 
and may return to normal when the patient recovers from the mental symptoms. The 
chief importance of high blootl-pressure is in diagnosing arterial or renal degeneration, 
with eonseijuenl tenderie\- to iiiio/ile.ri/ or to elironie lienri failure. It should be remembered 
Ihal any patient who is kept in bed lends to have a diminution in the blood-pressure, and 
this applies lo iirlciio-selerolie pal ients as well as others: a person may have a blood- 
pressure of 2.,0 mm. Ilg or more when up and about, and yel when lie is kept in bed the 
pressure may fall lo 1 ."lO mm. Ilg. to rise again wlien he relurns to aelive life. Prolonga- 
tion of the lirsl soiiikI al llir impulse or a ringing aceent iial ion of Ihc aoilie second 



82 BLOOD-PRESSURE. ABNORMAL 

sound, may ser\e to indicate tliat tliere is a high blood-pressure wlien no instrument 
is at liaud to verify tlie fact. 

Abnormally low blood-pressure of moderate degree may be observed in many different 
circumstances associated with asthenia ; it is apt to accompany Graves's disease : and exces- 
sive smoking of cigarettes ; but in itself a low maximum systemic blood-pressure is seldom 
of diagnostic significance excepting in Addison's disease. In a case in which the degree of 
pigmentation of the skin or of mucous membranes may leave doubt as to wliether .'Vddison's 
disease is the diagnosis or not, a blood-pressure so low as 80 mm. Hg would be confirmative 
of the diagnosis, although tliere are cases of Addison's disease in which the blood-pressure 
may be no lower than 110 mm. Hg. Herbert French. 

BLUE SCLEROTICS. — (Sec FRACTrnE. Spontaneous, p. 2J.2.) 

BLUE-BRAIN.— (See Dead Fingers, p. 162.) 

BOILS.- (Sec Pi-sTrLES. p. 557.) 

BONE, SWELLING ON A.— (See Swelling on a Bone, p. (i(i7.) 

BONES, SPONTANEOUS FRACTURE OF.— (See Fractlre. Spontaneous, p. 242.) 

BORBORYGMI are gurgling noises in the abdomen produced by peristaltic move- 
ments of the bowel acting upon the mixed gaseous and fluid contents. With the stetho- 
scope applied to the abdomen they may be heard in all normal persons, varying in intensity 
at different jjhases of digestion. When a meal has been taken after a period of fasting, 
the passage of the intestinal contents through the ileoca;cal valve may be heard distinctly 
with the stethoscope placed over tlie rigtit iliac fossa some six hours or less after the meal ; 
but it is seldom possible to decide what precise portion of the bowel is responsible for the 
]iroduction of borborjgmi heard elsewhere. 

Normally, these sounds should not be audible either to the ])atient or to other persons : 
but occasionally even in health they may be heard quite loudly. In some individuals 
indeed, especially in women, the sounds become annoyingly obtrusive, and they may even 
acquire a pathological degree. They may be very loud when a person is beginning to get 
over-hungry. It may be very difficult, however, to decide exactly as to their cause : some- 
times the patient seems to be otherwise perfectly healthy. More often there is evidence ol' 
functional nerve disorder or hysteria, so that the borborygmi may be due to functional 
errors in the intestinal peristalsis or in the secretions within the bowel. They may be 
associated with Flatulence (p. 240), though by no means necessarily so. Observation 
of the patient may detect air-swallowing ; intestinal putrefaction is indicated by excess of 
indican in the urine, or by a high ratio of organic to inorganic urinary sulphates ; fermenta- 
tion of carbohydrate is suggested when there is no evidence of air-swallowing, when urine 
analyses do not confirm any suspicion of proteid putrefaction, and when the borborygmi 
are increased by carbohydrate foods. 

IJorborygmi are apt to be increased in asphyxial conditions, and may be very marked 
in cases of heart failure with cyanosis. 

The absence of borborygmi may sometimes be important, for one of the first effects of 
peritonitis is to inhibit peristalsis ; without peristalsis borborygmi cannot be produced, 
and therefore, if ]3eritonitis is suspected, the presence of well-marked borborygmi on auscul- 
tation of the abdomen is an argument against there being general peritonitis, whilst com- 
plete silence of the abdomen is in favour of this diagnosis. Herbert French. 

BRADYCARDIA, or undue slowness of the pulse-rate, is compatible with health, 
some iTidividuals having a normal pulse-rate of 50, whilst in a few it does not exceed 40 or 
even 30 per minute. Occasionally bradycardia of this kind is foimd in more than one 
member of the family. It is important to auscultate the heart to exclude the possibility 
of the rate of the pulse as felt at the wrist not being the same as the rate of the heart-beat ; 
often, jjartieularly with mitral stenosis, by no means every pulse wave becomes palpable 
at the wrist, and the rate may then seem to be slow when perhaps in reality it is twice the j 
apparent rate. 



BRADYCARDIA 83 

Absolute slowness of the pulse-beat, as distinct from its relative slowness in proportion 
to the pyrexia, is best seen in the symptom-complex termed Stokes-Adams' disease, the 
phenomena of which are syncopal attacks associated with epileptiform convulsions, coma, 
stertor, and cyanosis, the rate of the heart-beat being found to have dropped to a half or 
even to less than half of that which is natural. These symptoms are due to difliculty in 
the transmission of the contraction-stimulus from the auricle to the ventricle alono- the 

Time marl, - [ I ' I ' 1 — 
jiigs in i, and [_ _ _ -_zrr- 




Fi'j.' iT.—ElKtro-cardiosami sLowiiif.' complete licart-block. The aurit-vihir waves ( p) recur 
at ci|Ual intervals, but bear no relationship to the ventricular waves. lAt X the auricular and 
tlie ventricular waves'are simultaneous. 

auriculo-vcntricular bundle of His. The inhibitory factor is not the same in all cases, but* 
is often associated with arteriosclerosis and dejjenerative changes in the bundle of His, 
together with myocardial degeneration and atheroma of the coronary arteries ; or to .syphilis 
of the bundle of His or to destruction of that bundle by a gumma^ sarcoma, or carcinoma. 
The diagnosis is apt to be that of epilepsy until the fact has been established that the pulse- 
rate falls during an attack to about half the normal ; but when this observation has been 
made, the difference between Stokes-Adams' disease and ordinary epilepsy is clear. The 




had 
Left 
left l<-B 



-nnielimcs cvhibit,..! panial I t-lilock as al.ovc, ami soiuii iiiii-s corMplcCc, as in I'l.j. W. . 

I''"" '"ii arc those of ' heart-block' the diagnosis of which in its lesser degrees caniiol 

be made without careful instrumental records i.C the venous and .■irlerial pulses and of the 
cardiac movcmculs, made either l)y means d I he pdlygniph. or l>etter still the electro- 
cardiograph. (■onsid(ral)Ic slowing of the pulsc-nilc has also been noted in souie cases of 
iirwinia. even without licarl -bloc^k ; both in the chronic type of the alTection and during 
uneniic coma. IJnidyeardia is by no means constant in iira'mia however. 

Increased inlnit raiiial pvcssiuc sometimes causes bradvcardia in certain cases of 



K-t 



BRADYCARDIA 



cerebral heemorrJiage. tumour or abscess, and in the early stages of tuberculous meningitis : 
in other forms of meningitis, and in the later stages of tubercnlous meningitis the initial 
bradycardia changes to tachycardia. If in a given case there is otitis media or some 
other local infective focus which might produce a cerebral abscess, pyrexia with a pulse- 
rate of 50, 55, or 60 is an argument in favour of intracranial abscess ; the other complications 
of otitis media, especially lateral sinus thrombosis, mastoid abscess, or suppurative 
meningitis, jiroduce a rapid pulse-rate instead of a slow one ; the reverse is not true, for it 
is not possible to exclude cerebral abscess merely on the ground that there is no bradycardia. 
Cerebral tumour can generally be distinguished from cerebral abscess by the greater length 
of the history, the more pronounced optic neuritis, or the absence of predisposing cause to 
cerebral abscess, such as otitis media or bronchiectasis ; whilst cerebral haemorrhage is more 
rapid in its onset, is less likely to have marked optic neuritis, and if there is pyrexia it is 
apt to be extreme, reaching the level of hj'perpyrexia ; generally the patient is an elderly 
man who has cither high blood-pressure, albuminuria, or other evidence of degenerated 
arteries or granular kidneys. 

In myxcedema the pulse-rate is seldom fast, and it may be abnormally slow. 

Certain drugs are apt to slow the heart markedly when they have been administered 
in full doses over a long period, the three most important being digitalis, strophanthus, and 
sodium salicylaic : the diagnosis depends on knowledge of the medicine the patient is taking. 

Jaundice is generally stated to cause marked slowing of the pulse-rate : it is true that 
artificial introduction of bile salts and pigments into the circulation in animals slows the 
heart, but clinically in man it is rare to find jaundice and absolute bradycardia associated. 

Herbert Frenclt. 

BRADYPN(EA, or imdue slowness of breathing, is not a very common symptom, 
hut it may be met with in marked degree imder various conditions, of which the following 
are the chief : — 



1. As an Effect of certain Drugs or Poisons : — ■ 

Clil<irol(iriii Chloral Suli)lional 

Opium 



•plua 
iIkiI 



Chloral 

Chloral hvilrate Triona! 

Butyl eliloial liydrate Tctroual 

Veronal Jlediiial 



Cerebral Compression resulting from : — 

Depressed fracture of the i Pontine ha'niorrhage 

skull Cerebral tumour 

Meningeal hoemorrhage Cerebral abscess 

Ccreliral ha'moirhaiie ] Cerebellar tMniour 



Aconite 
Antimonv. 



Cerebellar abscess 
Osteoma of tlie cranium 
Gumma of the meninges. 



3. Shock or Collapse from : — 

Severe injury 

.Sudden onset of acute illness 

4. Caseous Bronchial Glands. 

5. Functional Conditions : — 

Hysteria [ Ki)ilepsy 

6. Ursemia. 



Operations 

E.xeessiveloss of Ihiid IVom eliolcraic diarrhcra. 



I Catalepsy 



I Trance. 



7. Diabetes Mellitus with impending Coma (' Air-hunger '). 

Although l)radypn(ea may result liciiii any of the above causes, it is not constant in 
most of them, and in the majority it is an incident which, even if present, is not of 
diagnostic importance. This applies particularly to the conditions mentioned in Groups 
(1) and (2), in many of which the jjatient is likely to be at least stuporous, and perhaps 
completely comatose (see Coma, p. 117). The cerebral lesions will be indicated by assoc; 
ated headache, vertigo and vomiting, and confirnied by the discovery of optic neuritii 
(Plate XIX, Figs. K. L. p. 416). 

Now and then, in the case of a child suffering from tuberculous meningitis, one comes 
across a curious type of slow breathing, in which two or perhaps three short respirations 
occur in quick succession, followed by so long a pause that the patient may appear to be 
dead. This type, known as Biofs breathing, does not resemble Cheyne Stokes" breathing 
(p. 107) clinically at all, but it is probably related to it pathologically. It occurs in those 



JS 

if 



BRADYPNCEA 85 

who arc ap])roac'hino death, but may be present for a day or more before dcatli actually 
occurs. 

If the bradypna?a is due to a poison, the circumstances of the case may suggest this, 
and it may be confirmed by chemical analysis of the gastric contents or of the contents 
of adjacent bottles ; though there may be the same difficulties of deciding whether the 
patient is " drunk or dying," as are discussed on p. 118. One important point is not to 
conclude forthwith that the presence of sugar in the urine indicates diabetic bradypnoea 
and coma, for mmibers of patients suffering from deep alcoholism have sugar in their urine 
for the time being ; generally, however, without acetone (p. 3) and in a low specific 
gravity urine. 

In cases of shod: or coUapsc the existence of bradypncra will be overshadowed by the 
other symptoms in the case, and it is not in itself important. 

The slow breathing that results sometimes from caseous broncliial glands differs from 
most of the above in that it affects patients, generally children, who are not acutely ill ; 
though delicate, they may even be going to school, and yet their respiration rate may be 
as slow as 12 or even 10 to the minute for weeks or months. There is generally tachy- 
cardia at the same time. Many sucli children shake oft their delicacy in the course of 
a year or two, for the majority of cases with caseous bronchial glands get well without 
being diagnosed ; but the relationship between this bradypncea and affection of the glands 
has been established repeatedly in patients dying from accident or other causes. During 
life the diagnosis may be established by finding the shadow of the caseous glands in the 
thorax with the .r-rays (Fig. 01, p. l-t9). 

Little need be said about the functional conditions in which bradypnoea may occur. 
Old people tend to breathe iruich more slowly than young unless there is shortness of breath 
from emphysema, bronchitis, or myocardial affection. Epileptics breathe normally 
between their attacks ; but during a seizure they cease breathing altogether for the first 
twenty seconds or so — the tonic stage — and then their respirations start slowly and 
stertf)rously ; the bradv'pnoea may then cease suddenly, or it may persist in minor degree 
during the period of post-epileptic stupor. Ilysleria may produce almost any symptom ; 
brady])nnea is possible though tachypnoea is more common ; the diagnosis depends upon 
other features of the case (p, 465). Cntalcpsi/ and trance are both mental conditions, 
diagnosed by watching the case or by the history ; in catalepsy the movements of respira- 
tion may be very slow, but they are obvious : in trance, on the other hand, the breathing 
movements may be apparently absent altogether for days or weeks, the patient lying 
motionless like one dead. The chief dilfieulty is to exclude actual death ; the thermometer 
helps nnieh — the body docs not become cold : the lieart sounds may be just audible even 
though the pulse (antiot be felt : and the fact that some respiration is taking jilace may 
be reiogni/.ed by holding a bright mirror close to the nostrils and mouth, when a slight 
dimming from condensation of expired air will be seen. In very exceptional cases, how- 
ever, death is simulated so closely that the patient lias been upon the point of being 
buried before the mistake has been discovered. 

L'ra'niia may be associated with breathing that is either ripid. or normal, or slow ; 
the latter is cxcc[)tional ; but in sonic eases of unemie coma bradypncea is pronounced. 
Cerebral ci)Tnpr(ssif)n by a hiemorrhage. abscess, or tumour may be sinuilalcd, and a 
knowledge that the urine contains albumin and tube easts, au<l that the blood-pressiu'c is 
high, will not always decide between them. Ueeurrent convulsive seizures would ijoint 
to ura-niia to some extent, but they may also occ.ir from gross brain lesions, and optic 
neuritis may also be common to both. To clinch the diagnosis of ura-mia it may be 
necessary to lest blond or cerebrospinal flui<l to see if it contains excess of urea. 

Dialjclcs niellitiis is lial)le to cause the most characteristic bradypncea of all — the 
'air-hunger" of diabclic coma. This is not a dyspncca, as the name niight suggest, but 
a condition of extremely deep slow breathing with a tnaximum respiratory excursion both 
in the intake and in the output of air. The " hunger ' for air is one of getting the 
niaxituum of air in and out with each deep slow breath, rather than one of getting in as 
many breaths as possible in a given time. The patient becomes increasingly drowsy, and 
generally complMius of pjiins in the upper half of the ahdouien. 'I'lie breathing rale bigins 
to fall from f,S to 1(1, to If. anil progressively .lown lo perhaps only li lo llie minulc. 
There is a long pause between each brealli. and llicn inspiration slarls and. willioul any 



86 BRADYPNCEA 

Ininv, the stupcrosc jjatient ijoes on drawing aiv deeper and deeper into his chest until 
lie cannot expand it to take in any more ; the head is often thrown slowly back during 
the process, the mouth slowly opens wider and wider as the head goes back ; then there 
is a pause at the height of inspiration before an equally deep, slow, solemn expiration 
follows, and the head comes forward and the mouth closes partially until the next slow 
deep inspiration is in progress. The patient seldom lives much longer than forty-eight 
hours after this onset of air-hunger and diabetic coma, but the air-hunger is sometimes 
seen in cases not yet comatose. It may then pass off for a time, but it is always a sign of 
grave danger, and it is the most characteristic of all the forms of bradypnoea. 

Herbert FrencJi. 

BREAST, DISCHARGE FROM.— (See Dischakgk from tiik Nipple, p. 181.) 

BREAST, PAIN IN. -(See Pain ix the Breast, p. 429.) 

BREAST, SWELLING OF THE.— (See Swelling, Mammary, p. 085.) 

BREATH, FOULNESS OF THE. — This is due to one or other of four main groups 
of conditions, namely, septic and putrefactive changes within the mouth or nose ; septic 
or putrefactive changes within the lungs ; smoking or the ingestion of substances, such as 
garlic or onions, whose products are excreted by the lungs or saliva ; and severe toxic 
conditions, espeeiallj' those affecting the alimentary canal or peritoneum. 

\Mien the foulness of the breath is not habitual, but occurs as the result of recent illness, 
there will be symptoms of the latter which point to the diagnosis quite apart from the con- 
dition of the breath, and one need merely indicate as possible causes such things as typhoid 
fever, general peritonitis, post -puerperal sepsis, intestinal obstruction, and a host of other 
conditions of this kind in which, even though the mouth be clean, there may be foulness of 
the breath, such tendency being greatly exaggerated if sordes have been allowed to collect. 
Foulness of the breath due to the ingestion of foodstuffs such as onions or garlic is 
familiar enough ; there are certain drugs, for instance gnaiacol or paraldehyde, which may 
produce a similar symptom without the patient's friends realizing why the breath should 
be so tainted. 

Foulness of the breath due to lung conditions will nearly always be indicated either 
by the abundant and putrid sputum, or by the abnormal physical signs, in the thorax. 
The condition may be due to pMhisis with secondary infection of the cavities by pyogenic 
organisms, fa;lid bronchitis, bronchiectasis, gangrene of the lungs, empyema or other abscess 
which has ruptured into the lung. The cases which give rise to most difficulty in differential 
diagnosis are those in which an empyema has been situated deeply, for instance between 
the lower lobe and the diaphragm, or between two lobes, without reaching the surface ; 
there may be absolutely no abnormal physical signs, and the diagnosis has to be made from 
the symptoms and history. The patient has generally had some obscure febrile illness,, 
possibly with cough, but without much expectoration, until one day, after a particularly 
severe bout of coughing, a large quantity of pus — perhaps a teacupful or more — has been 
brought up suddenly, since when, at intervals of hours and days, there has been similar 
expectoration of quantities of putrid pus. Deep-seated empyema without abnormal physical 
signs most resembles bronchiectasis or bronchiolectasis, but is distinguished by the sudden , 
way in which the first large quantity of purulent expectoration came on. In both cases 
there may be clubbing of the fingers, the sputum contains pus corpuscles and pyogenic and 
non-pyogenic micro-organisms other than tubercle bacilli, but no elastic fibres indicative 
of lung destruction. 

Gangrene of the lung produces an unmistakable stench of the worst kind ; the detection 
of elastic fibres in the sputum, after boiling with caustic soda to destroy other tissue 
elements, clinches the diagnosis. 

Phthisis with cavitation may produce foulness of the sputum, but hardly ever the stench 
of gangrene, unless gangrene has supervened. It is distinguished from bronchiectasis and 
from hidden empyema by discovering tubercle bacilli in the sputum. The chief difficult 
arises when the tuberculous part of the malady has ceased, the cavities formerly excavatu 
by the tuberculous process having been usurped by secondary pyogenic organisms. 



BREATH. SHORTNESS OF 87 

Foul breath is due in the great majority of cases to local decomposition in the mouth, 
often diagnosablc on simple inspection in the form of tartar, septic gums, carious teeth with 
decomijosing food ])articles in them, pijorrluea alvcolaris, or stomatitis (p. 542) ; or it may 
he that the nose or tliroat are at fault rather than the mouth, as the result of necrosis of the 
7iasal bones, purulent hypertrophic or atrophic rhinitis, ozocna, septic tonsillitis or other varieties 
of Sore Throat (p. 613) ; very vile foulness of the breath occurs with Vincent's angina 
(p. 614), and with scpianious-celled carcinoma of the mouth or tongue : in children the 
possibility of some foreign body having got impacted in the throat, nose, or nasopharynx 
should not be forgotten. 

It is only when all such local conditions have been excluded, and when there is no acute 
illness nor any lesion of the lungs, that one can attribute foulness of the breath to constipation 
or to dyspepsia. It is sometimes very difficult to find out why the patient's breath is not 
sweet, and indeed there are some persons in whom all the functions of the body seem to be 
normal, and the mouth clean, and yet the breatli is foul. If there are any symptoms of 
gastro-intestinal disorder, especially flatulence or constipation, one is inclined to attribute 
the condition of the breatli to the stomach or the bowels ; but when there are no symptoms 
of error in these, it is more than likely that the trouble is due to some local condition not 
discovered on ordinary insiiection, particularly putrefaction of food particles which may 
become impacted between the teeth even in persons who use both tooth-brush and mouth- 
wash daily. Herbert Frtiicli. 

BREATH, SHORTNESS OF.— This is a very common complaint which should be 
differentiated c.Trcfully lioin dilliiulty of breathing, the hitter term being reserved entirely 
for cases of obstruction in the main air-passage, the larynx, and trachea — diphtheria, 
growths, and, very much more rarely, pressure from without being the main causes. Short- 
ness of breath is, in the patient's mind, a conscious quickening of the resjjiratory movements 
to supply a conscious need of air. The following are chief causes : — 

Increased Need for Oxygen. — Fevers and other septic processes inducing excessive 
oxygen requirements. Exercise in health — temporary shortness of breath. 

Diminished Supply of Oxygen. — (1) Blood conditions in which the red corpuscles 
cannot carry a sufficient charge, or do not yield up their supply with sufficient ease ; 
(2) Cardiac conditions of inefficiency of circulation ; (3) Pulmonary conditions of diminished 
surface of contact, or ease in contact, of air and blood in alveoli ; (4) .A.tmosphcric con- 
ditions of diminished j)artial oxygen pressure in the alveoli of the lung ; (.5) Deformities 
of the ehesl nicclianically ])reventing tlie expansion of the lung. The diagnosis of these 
condilions is not (Hllicidl when once attention is drawn to the possibility of their occurrence, 
but we must advert briclly to each of them to indicate the guides to the cause in a case 
not at once obvious. 

Fevers and Septic Conditions. — The tliermometer and the obvious illness of the 
patient will gcncially iiuliciilc these : nor indeed is shortness of breath a common complaint 
in such patients, their minds being filled with other ideas. 

Exercise in Health. — Here it is necessary to be sure of the health ; it may or may 
not be that the person is merely out of condition, and undertakes exercise which only a 
trained athlete can perform i)ropcrly. The only way to avoid mistakes is to ask. Docs 
the shortness of breath soon disappear ? and then to make a careful examination of the 
patient to sec if imy of the midcrmciitioiied eawses are at work : - 

1. Blood Conditions. These iiicludr : (i) Siiiiplc loss of lilood : (ii) Antcrnia simplex : 
(iii) .Aiiatnia, severe, pernicious or Icukaniie ; (iv) Polyeylhutiiia ; (\) .Somi' pathological 
constituent, as in diabetes, ura-mia, (iravcs's disease, etc. 

The actual laboratory diagnosis of the blood condition is simple enough if we decide 
to have it examined. The jioints that may lead us to have this done would naturally eonie 
in the following order. \ history of loss of blood is pretty sure to be voluutceicd -piles, 
excessive menstruation, obvious trauma, loss at parturition, etc. ; suspicion is very likely 
to be aroused by the colour of the patient's face, especially when eouple<l with a primary 
complaint of shortness of l)reath. Didlicles and nnemia are likely to show other signs, and 
the urine will give the clue to the diagnosis. Never omit to have the blood examined it 
the <-ause of a shortness of breath is not apparent on simple physical examination ; indeed, 
line iiiiisl go larllicr. and say if some <!isily iliaguosablc eoiwlition is not present : I'or il 



88 BREATH. SHORTNESS OF 

must be remembered that blood conditions are the very ones to be tlie exciting cause of 
cardiac inefficiency, wliicli by itself is often liard to diagnose it there be no obvious bruit 
or irregularity in rhythm. 

2. Cardiac Conditions. — Inefficiency in circulation. These include : (i) Valvular 
disease (acute and chronic) : (ii) Muscular weakness (fatty, fibrosis, etc.) ; (iii) Nerve 
conditions (arrhythmia ?) ; (iv) Pericarditis and pericardial effusion. 

i. Valvular Disease. — If a bruit be present, it may fairly be assumed that the heart is a 
factor in causing shortness of breath, but unless some other tell-tale sign be present it must 
not be assimied that it is the only factor, for it is very common to find patients with bruits 
who will not confess to shortness of breath. 

ii. Muscular Weakness. — We cannot under the jjresent heading give all the points in 
connection with " morbus cordis sine murmure " ; it must, however, be stated that a 
diminution in the muscular energy of the heart is a most important contributory factor in 
producing shortness of breath in all ]jathological conditions of the blood, including renal 
affections and diabetes, in convalescence from acute disease, and in acute pericardial 
affections ; it is, perhaps, the commonest cause of all of shortness of breath. Want of 
tone in the soimds, likeness of the first to the second sound, and irregularities in rhythm, 
are the jjrincipal points to look for. The lu'ine should be examined with care, both for 
albumin and tube-casts ; the ophthalmoscope should be used in the detection of albuminuric 
retinitis ; and it is often wise to measure the systemic blood-pressure to find out whether 
it is greatly above the normal or not. In tliis connection fat wants special mention ; fatty 
degeneration of heart muscle, and overloading of the heart with interstitial fat will both 
cause shortness of breath, and it is practically impossible to differentiate the two with 
certainty during life. In very stout individuals the latter is of course to be suspected, but 
the former cannot be excluded ; in fact, when such a patient complains of shortness of 
breath, his case requires the greatest acumen to decide the cause and then the treatment. 
The previous general health affords the strongest clue, coupled with the history of the onset 
of the shortness of breath. In a stout subject, as indeed in all other patients in whom I 
am trying to judge the question, " Am I dealing with a case of cardiac insufficiency without 
a bruit ? " I adopt the following simple plan. I listen with the stethoscope to the heart, 
counting the pulse frecjuency and noting the sounds while the patient is sitting in a chair 
in the course of conversation, and again do the same while he is standing. I then make 
the patient hurry in his niovemcnts. run upstairs, or several times across mj' consulting 
room, and again repeat my observations on frequency, rhythm, and sounds ; I then get 
him to lie down on a sofa whilst I make anotlier examination on the same points. It is 
thus possible in three or four minutes to get most valuable information as to the response 
of the heart to increased work, as well as to relief from work, and to draw jjretty accurate 
conclusions as to its muscular efficiency, which after all is the chief point to be considered. 
I roughly assume that there is an average difference in Iiealth of about five beats per 
minute between sitting and standing, that effort should increase this difference to somewhere 
about fifteen to twenty beats a minute, and then in about three minutes a reasonably healthy 
heart should resume its resting frequency from such mild exertion as mentioned abo\e. 
If exertion removes a ' resting ' irregularity in rhythm, I assume the heart is muscularlj' 
in a reasonable state of health. 

iii. Nerve Conditions. — I_,ocal pressure on the nerves may cause cardiac arrhythmia 
and breathlessness, but these will have other signs and symptoms easily discoverable ; 
general nervousness and neurasthenia are often characterized by shortness of breath on 
exertion or excitement, there being frequency of the beat without any arrhythmia. 

iv. Pericardial Diseases. — A differential diagnosis between these and a hypertroph>' 
or dilatation of the ventricles may be demanded for other reasons, but qua shortness of 
breath, there is no didiculty in determining that either cardiac or pericardial trouble is tlu- 
cause. 

3. Pulmonary Conditions. — These, again, will be fairly obvious on proper examination, 
including, as they do. every disease of the lung ; but we would specially draw attention to 
the possible presence of a quiet pleural effusion, which not very infrequently is so insidious 
as to give rise to no complaint but that of shortness of breath. Again, in the early days 
of phthisis, it may be that a cough and shortness of breath are nearly all that is complained 
of. Bronchitis, advanced tubercle, broncho])neumonia. lobar pneumonia, and acute 



BRUITS, CARDIAC 89 

])leiiri.sy, are all easily recognizable causes of shortness of breath. The only intrinsic 
affection of the lungs not at once easily discoverable is emphysema without its usually 
accompanying bronchitis ; the shape of the chest, the defieiency of \esicular sounds, the 
increased resonance to percussion will generally give a clue. 

4. Atmospheric Conditions need no diagnosis ; partial asphyxia by bad air, high 
mountains, and caisson work, are the three chief alterations in gaseous surroundings. All 
are obvious. 

5. Deformities of Cliest are again obvious : Pott's cur\-ature is the chief one. They 
derive their ini])()rtance from the fact that commonly one lung is Iiors de combat almost to 
start with, and hence a very slight affection of the other may cause great difliculty in 
breathing. Fred J. Smith. 

BREATHING, CHEYNE-STOKES.— (See Cukvnk-Stokes Rhspiuation. p. 107.) 

BREATHING, SLOW. (See Bkauvpncea, p. 84.) 

BRITTLE BONES.— (See Fiiacture, Spontaneol s, p. 242.1 

BRUITS, CARDIAC. 

I.— SYSTOLIC BRUITS. 

(A). Systolic Bruits in the Mitral Area. — When a definite systolic bruit is audible 
over the niitnd ana whicli ((irrcspoiuls to that portion of the chest w-all lying immediately 
over the cardiac apex, its cause is sometimes obvious. If, for example, a person who has 
I)reviously had an attack of rheumatic fever presents a bruit with its point of maximum 
intensity over the cardiac apex, conducted outwards into the left axilla, there being lost, 
and heard again near the inferior angle of the left scapula, then such a bruit is almost 
certainly due to organic disease of the mitral valve causing regurgitation through it. This 
is confirmed by finding that the heart is enlarged, the area of cardiac dullness increased, 
and the apex beat (lis])liiced downwards and to the left. Such enlargement points to the 
cardiac condition not lieing of recent origin ; bulging of the pra»cordia, often seen in children, « 
is additional evidence in the same direction. 

In some cases, however, the diagnosis is not so obvious, and for a definite conclusion 
to be arrived at it is necessary to consider all the following conditions whieli may i)ro(luce 
a systolic bruit in the mitral area : — 

(1). Mitral regurgitation, due to chronic organic disease of the mitral vahe. 

(2). Acute endocarditis : (d) Sinij)le : (,h) Ulcerative or malignant. 

(;j). -Mitral regurgitation where there is no disease of the mitral valve, but ililatation 
of the left ventricle as the result of («) Disease of the aortic vahe : (}>) Disease of the 
niyocardiiun, such as myocarditis. ])arcneliymatous degeneration. I'atty heart, fibroid heart ; 
(r) Disease external to the heart, causing hypertrophy and dilatation of the lell ventricle 
such as arterial sclerosis and interstitial nephritis ; (d) Adherent pericardium, which is 
lre(|ucnt!y associated with organic disease of the valves. 

( !•). Funclional bruits. 

(.■>). Cardiii-respiralory bruits. 

{()). Congenital malfortnalioii ol llie licart. 

(7). Aneurysm of the heart. 

(N). Acute ijcrlcarditis. 

I. The rollowiiig points are in laNour ol llic liiiiit being due to arfiii'iiii' ilisciisr iif llic 
inilnil j'fdvr of long standing : (ii) iMiIargerneiil of the lieart, shown by displacement of 
the apex bi'at and increase iti the area of cardiac dullness. In mitral regurgitation the 
enlargement is due to hypertrophy and dilatation of the li^l't ventricle, the differential 
'diagnosis ol' the other causes of which will be found on p. 2()(i : (h) \ history of ])ast 
rheumalie lexer or of chorea ; (c) The age of the patient : in children and young adults 
mitral regurgitation is far more likely to l»- the result of a previous endocarditis than of 
dilatalidii (if the mitral oriliee without valvular disease ; (rl) The absence of pyrexia lulps 
in exeludiiig a recent endocarditis, though in children sulTering from rlieuuiatie endocarditis 
the temperature is often normal while they are being treated with .salicylates. In cases of 
recent endocarditis there may be no physical signs of any great eidargcment of the left 
ventricle, and usually the apex beat is I'oiuid close to its iKuiiial position. 



00 BRUITS. CARDIAC 

2. Acute endocarditis is nearly always associated with some other affection ; for 
example, there may be, or have been, acute rheumatism or chorea, or pneumonia or some 
other infectious process, such as scarlet fever, erysipelas, septicaemia, or puerperal fever. 
The heart is not found to be enlarged, or only to a slight extent, provided that the condition 
is not one of an acute endocarditis affecting old sclerotic valves ; the bruit is soft and 
blowing — never musical in simple eases — and it is localized to the impulse instead of being 
transmitted into the axilla. In malignant endocarditis the constitutional disturbances may 
be severe ; the points in the diagnosis will be foimd on p. Si. 

3. The points in favour of mitral regurgitation due to dilatation of the left ventriele are : 
((/) The age of the patient : myocardial degenerations, except those occurring in infectious 
processes, are not likely to be present before middle life ; (h) The presence of arterial 
sclerosis and chronic interstitial nephritis, as determined by increased blood-pressure, 
accentuation of the aortic second sound, thickening of the radial arteries, retinitis, and 
polyuria with a trace of albumin ; (e) The existence of non-rheumatic aortic obstruction 
or regurgitation with hypertrophy and dilatation of the left ventricle ; (d) Shortness of 
breath and cardiac distress upon exertion, without any obvious cardiac lesion ; if these 
be associated with a:dema of the legs, engorgement of the lungs, and enlargement of the 
liver without a very high blood-pressure and without obvious primary lung trouble sueli 
as fibrosis or emphysema, dilatation of the mitral orifice as the result of myocardial 
degeneration is probable. If this is the result of fatty infiltration, the cardiac condition is 
often part of general obesity. 

Regurgitation through the mitral valve may be caused by a dilatation of the left 
ventricle dependent upon an adherent pericardium. The following signs of adherent peri- 
cardium must be looked for : (a) Systolic retraction, which is best determined by inspection 
of the chest wall from the side, and is due to an indrawing of the intercostal spaces during 
the ventricular systole. \Vlien this is situated near the apex beat it is due to an adherent 
pericardium : it may also be noticed over the lower sternal region, or at the ensiform 
cartilage, or over a lower left rib behind the posterior axillary line. Systolic retraction 
is not always due to an adherent pericardium, for in thin persons and in children a systolic 
indrawing of the third and fourth left intercostal spaces close to the sternum is often seen, 
and is produced by the normal recession of the base of the heart during each ventricular 
systole. Systolic retraction due to adherent pericardium is often followed by (b) The 
diastolic shock, palpable and due to the sudden relaxation of the ventricular wall ; (c) Eiastolic 
collapse of the veins of the neck, or Friedreich's sign, which is produced during the ventricular 
diastole ; it is found chiefly in this condition, but does not always occur, and is sometimes 
seen without pericardial adJiesion being present ; (d) The pidsus paradoxus, the cardiac beats 
becoming more feeble at the end of inspiration, so that during each inspiration the pulse- 
beat becomes very weak, or is lost. 

4. A systolic bruit at the cardiac apex may be functional in origin, in which case it is 
localized to the mitral area, being conducted only for a short distance into the axilla, and 
not heard posteriorly. The condition is associated with anemia and other debilitating 
conditions. Other functional bruits are nearly always associated with it, especially one in 
the pulmonary area, and also a bruit de diable in the neck. 

5. A cardio-respiratory Ijruit is frequently heard at the cardiac apex, and is sometimes 
mistaken for one caused by niitral regurgitation. The bruit varies with the movements 
of respiration, the more usual sounds heard being bruits corresponding with the ventricular 
systoles of two or three heart -beats during inspiration. Such murmurs should not be 
ignored, as they may be due frequently to pleuritic friction. To distinguish them from cardiac 
bruits is usually easy, and the chief diagnostic points are : (a) Cardio-respiratory bruits 
vary in intensity with the movements of respiration, being louder during inspiration. 
[b) When present at the apex they are abolished when the breath is held in deep inspiration 
(<■) They vary in intensity and character with alterations in the posture of the patient. 
((/) The bruits sound nearer to the ear than cardiac bruits, (f) Each bruit commences 
suddenly and ends abruptly. (/) They are not conducted in the recognized direction ol 
valvidar murmurs. 

6. A congenital systolic bruit, when heard in the mitral area, is always part of a loud 
bruit with its point of maxinumi intensity nearer the base of the heart. 'Wlien such ." 
nuumur is heard in children, with little or no displacement of the apex beat, and the are; 



BRUITS. CARDIAC 91 

of cardiac dullness is increased to the right of the sternum, the condition is always congenital. 
The lesion will generally be either patent septum ventriculorimi, pulmonary stenosis, or 
patent ductus arteriosus (p. 156). Mitral regurgitation due to a congenital defect practically 
ne^er occurs. 

7. An fineiiri/sm at the cardiac apex is rare, and is scarcely possible to diagnose, so that 
it need not be taken into account when considering the differential diagnosis of apical bruit. 

8. When acute pericarditis is present, a systolic bruit which is part of a ' to-and-fro ' 
friction murmur may be heard in the mitral area. Such a murmur changes its character 
with the pressure of the stethoscope and with the different phases of respiration : and it is 
not conducted into the axilla. Other signs of pericarditis are usually present (p. 213). 

(B). Systolic Bruits over the Pulmonary Area, i.e., over the second left intercostal 
space close to the sternum, may be caused by the following conditions : — 

(1). Congenital cardiac malfurniaiions, especially pulmonary stenosis and patent ductus 
arteriosus. 

(2). Fiinrtiuna! lirait. 

(3). Cardio-respiratorij Ijriiil. 

{i). Acquired pulmonary stenosis, which is a very rare lesion. 

To distinguish between an organic and congenital defect and a functional condition is 
usually quite easy. Pulmonary stenosis is nearly always congenital, and is therefore found 
for the most part in children ; and its presence is confirmed by other signs of congenital 
heart disease, such as little or no displacement of the apex beat with considerable enlarge- 
ment of the right side of the heart, together with cyanosis of varying degree, and clubbing 
of the fingers (p. Ill) and toes. With a. patent ductus arteriosus the bruit is often similar 
although cyanosis and clubbing of the fingers and toes are usually absent ; instead of the 
murmur being definitely either systolic or diastolic in time, a long rumbling bruit, com- 
mencing during systole and passing on into the diastole of the ventricles, is heard. Such 
a bruit is considered to be pathognomonic of this congenital defect, as it is impossible for 
a bruit extcnfling from systole into diastole to be produced within the heart. WTien a 
patent fluctus arteriosus is present, .r-ray examination of the heart sometimes shows a 
shadow bulging to the left between the arch of the aorta and the left ventricle. It 
appears like a "cap' above the ventricle, due to dilatation of the pulmonary artery. 
A'-ray examination will help in the diagnosis of most forms of congenital heart disease, 
because it shows definitely the enlargement of the right heart with little alteration in the 
position of the left border. 

Other congenital maH'ormations, such as a patent interventricular septum . may produce 
a systolic bruit in the pulmonary area, though the maximum intensity of the abnormal 
.sound is lower down on the left of the steriunn ; in many cases, however, the differential 
diagnosis of the ventricular congenital malformation is impossible. 

2. The functional pulmonary bruit is common in chlorosis and other ana'inic and 
debilitated conditions, and in exophthalmic goitre ; it is also frequent in school-children 
a't. 5 1. 5. The bruit alters with tlie position of the ))atient. being louder in the recumbent 
than in the erect pcjslurc, whereas in congenital dcfeets the ijosition of the i)atient lias 
verj' little inlluenee ujjon the loudness. The presence of a bruit dc dialilr in the neck conlirnis 
the diagnosis of the functional origin of the bruit, and there is generally no such increase 
of cardiac dullness to the right of the stermmi as occurs in congenital malformation and 
acquired i)ulnionary stenosis. A systolic thrill may be present in the pulmonary area botli 
in organic and functional conditions, but is more conunou in the former and therefore in 
favour of ])uInionary stenosis. 

.\ systolic bruit is frc(|ucntly heard over the ujipcr portion of the manubrium in young 
children in the sitting posture, when the head is so raised that the eyes arc looking directly 
up at the ceiling. It disapj)ears when the chin is lowered. It is usually of no importance, 
although it may be a sign of enlarged lympliatic glands at the bifurcation of the trachea. 

3. ('ardio-rispiralorif bruits are sonu'tinies heard at the base of the heart, and more 
often on the left side of the slerninn. Tliey vary with the niovcmenls of respiration and 
also with changes in the posture of the patient, but not in so dellnile manner as do the 
canlio-respiralory bruits which arc heard in the mitral area. 

t. Pulmonary sloiosis may be an acipiired lesion, although very rarely : if in a ycpiing 
adult such a liruit as lias just been described is present, and if tlicrc is a |)asl hislory of 



9-2 BRUITS. CARDIAC 

iliciimatio fever, together with lesions of the other valves, espeeially the mitral, then it 
may be fairly presumed that the bruit is due to an accjuired pulmonary stenosis. The 
history helps greatly in the diagnosis, for if the lesion were congenital there would be 
symptoms of its presence dating back to infancy. 

Systolic bruits due to other valvular lesions may also be heard over the pulmonary 
area, but they have their point of maximum intensity over other portions of the pra"eordia, 
and are only heard over the ])ulmonary area on account of their loudness and extent. 
Tliese bruits are not likely to be mistaken for tliose that have just been described. 

(C). Systolic Bruits over tlie Aortic Area. — When a systolic bruit is heard with its 
point of maximum intensity in the aortic area, which corresponds to that portion of the chest 
wall overlying the second right costal cartilage, and is conducted upwards into the vessels 
of the neck, it arises either at the aortic valve or in the ascending portion of the aorta. The 
chief point in the diagnosis between these two conditions is the character of the aortic second 
sound. If the bruit be due to changes in the valves causing obstruction, then the second 
sound will be altered in character, being muffled and sometimes inaudible, as the rigidity of 
the aortic cusjjs prevents them closing suddenly in the normal manner. The presence of 
an aortic diastolic bruit would make quite clear the valvular origin of the systolic bruit. 
When the bruit is due to changes in the aorta, in consequence of atheroma, dilatation, or 
aneiuysm, and not to aortic obstruction, then the second sound is usually clear. The 
presence of a pulsating tumour, pulsation in the second right intercostal space without a 
timiour, or dullness in this region, would suggest an aneurysm and so confirm the diagnosis 
of the bruit arising in the aorta. A systolic bruit over the aortic area is of frequent 
occurrence ; but for the purpose of diagnosis it must be remembered that such a bruit is 
rarely due to stenosis, and more frequently results from a progressive sclerosis of the aortic 
valve without real stenosis, or from changes in the aorta. Before aortic stenosis is diagnosed 
there should be a loud systolic bruit in the second right intercostal space, together with a 
systolic thrill, and evidence of hypertrophy of the left ventricle. If the bruit is due to 
acute eixlocarclitis, with vegetations on the semilunar valves, then the left ventricle is not 
enlarged to such an extent as in aortic obstruction, or in atheroma of the aorta. Afunctional 
III- ait confined to the aortic area is very rare, but may be distinguished by there being no 
enlargement of the left ventricle, and by the presence of other functional bruits, especially 
a bruit (le (liable. If marked amcmia exists, either from some primary blood-disease or 
secondary to a cachectic condition, due to malignant disease, tuberculosis, malaria, a large 
haemorrhage, etc., then the diagnosis of a functional bruit is confirmed. 

In rare cases a very loud systolic bruit in the aortic area is due to a saccular aortic 
aneurysm opening into the pulmonary artery or into the superior vena cava ; in either case 
there will generally be a history of acute dyspnoea developing suddenly, together with 
cyanosis ; and when the superior vena cava is opened into in this way there is generally 
acute oedema of the face, neck, and arms also (Fig. 99, p. 208). A'-ray examination may 
assist the diagnosis materially in either case. 

(D). Systolic Bruits over the Tricuspid Area. — A bruit heard best over the tricuspid 
area, which corrcsjionds to that ])art of the chest wall overlying the lower portion of the 
sternum, is of diagnostic importance in that it indicates tricuspid regurgitation, which is 
nearly always due to dilatation of the right ventricle. That the bruit is due to tricuspid 
regurgitation is confirmed by finding the cardiac dullness extending to the right of the 
sternum, fullness and pulsation in the veins of the neck, and evidence of failing cardiac 
compensation, as shown by oedema of the legs, and enlargement and pulsation of the liver. 
Many bruits, systolic in rhythm and produced at the tricuspid valves, are best audible in 
the neighbourhood of the cardiac impulse, l)ut they are not conducted outwards into the 
left axilla like bruits ]jroduced at the mitral valve. On the other hand, when a mitral 
systolic bruit is loud enough, it may be audible in the tricuspid area, but there would not 
be the signs of passive congestion unless there was general failure of compensation. It 
should be borne in mind, of course, that tricuspid regurgitation often occiu's without pro- 
ducing any bruit at all, so that absence of sytolic bruit does not exclude tricuspid leakage. 

II.— DIASTOLIC BRUITS. 

A diastolic bruit heard over the precordia is always due to organic disease of the heart. 
If it be piesent over the aortic area, that is, over the second right costal cartilage close to 



BRUITS, CARDIAC 93 

the sternum, and conducted downwards along the left border of the sternum, and sometimes 
outwards towards the cardiac impulse, then the bruit is due to aortic regurgitation. 
Sometimes its point of maximum intensity is in the aortic area, sometimes to the left of 
the sternum in the third intercostal space. Examination of the pulse confirms the diagnosis, 
for the ■ water-hammer ' pulse is found only with aortic regurgitation. Capillary pulsation 
is also present ; it is demonstrated by placing a glass slide on the everted lower lip, or by 
pressing the finger nail so that the proximal half of it remains pink and the other is 
blanched, or by stroking the forehead firmly with the finger and watching tlie alternate 
blanching and reddening of the resultant streak. Capillary pulsation may also be found 
in cases of marked anaemia, and in the normal person in a Turkish bath. A double 
murmur is frequently heard over the larger arteries in aortic regurgitation, particularly 
over the femoral artery, where it is spoken of as Duroziez's sigyt. The first murmur is 
produced when the vessel is distended with blood, and the second when the blood-pressure 
suddenly falls on account of the regurgitation. 

As the diastolic bruit of aortic regurgitation is frequently associated with a systolic 
one, the result of aortic obstruction, a ' to-and-fro ' murmur is produced which may some- 
times be mistaken for pericardial friction sound. In pericardial friction the systolic and 
diastolic sounds do not commence accurately with the first and second soinids of the heart, 
arc not conducted in the recognized direction of an endocardial bruit, and are altered in 
intensity by the pressure of the stethoscope. Having decided that the bruit is due to 
aortic regurgitation, it must be remembered that such a lesion may be the result of : — 

1 . A progressive sclerosis of the aortic vahes, being part of a general arterial degenera- 
tion, or due to a localized sj'philitic lesion. 

2. Endocarditis, either rheimiatic or malignant. 

;{. Rupture iij (I segment, due to either excessive strain on an already diseased valve, 
or to malignant endocarditis. 

!■. Dilatation of the aortic ring, secondary to dilatation or aneui'vsm of the ascending 
portion of the arch of the aorta. 

5. Congenita! nialforniiition. 

The age oi the patient helps greatly in the differential diagnosis : if the lesion be found 
in a child or young adult, the condition is almost invariably the result of endocarditis ; 
if, on the other hand, aortic regurgitation occius in middle life, it is nearly always due to 
sclerosis of the aortic valve, especially sy])hihtie, and the diagnosis is confirmed by finding 
a positive Wassermann reaction, or degenerative changes in other arteries, chronic renal 
di.sease, and considerable hypertrophy of the left ventricle. If the regurgitation be due to 
dilatation of the aortic ring. It can only be diagnosed when the existence of dilatation or 
aneurysm of the aMciidiiig ]>orlion of the arch of the aorta, is indicated by dulliuss in the 
second right intercostal space close to the sternum, by i)uIsation or a ])ulsating tumour 
in this area, or by an ,r-ray examination. Sometimes the aneurysm may be situated just 
above the sinuses of Valsalva, and, while producing aortic regurgitation by causing dilata- 
tion of the aortic ring, may give no other ))hysical sign of its presence. It may be very 
small, and yet may cause sudden death by rupture into the pericardial sac. 

A diastolic bruit heard only down the left border of the sternum is practically always 
due to aortic regurgitation, but on some occasions it may be i)r<)duced by pulnionari/ 
regurgitation as the result of endocarditis, dilatation of the pulmonary ring, or a con- 
genital defect. I'lilmonary regurgitation is most often secondary to mitral stenosis, due 
to dilatation of the pulmonary orifice as the result of increased pressure in the pulmonary 
circulation. The other two forms are very rare, and dilliciilt to distinguish I'idm aortic 
regurgilalion unless there is evidence of enlargement of the right ventricle and iml nl llie 
lelt, and then- is no " water hammer " pulse as in aortic regurgitation. 

Diastolic hniils aodililc al the <unliac impulse are flue either to endocarditis of the 
mitral vaKc. to milral stenosis, or to aortic regurgitation. An aortic diastolic bruit is 
often eoiidiicled as far as the cardiac apex iind replaces the second sound here ; sometimes 
the iliMslolic bruit which is hcar<l in the aortic area is lost on being traced down the lell 
border ol' the sternum, to reappear at the ajiex. 'i'hc diastolic bruits of mitral stenosis can 
be distinguished by their appearance later in the diastolic period, and the most common 
i.s presystolic a crescendo murmur ending in a loud slapping liist sound. .\n aortic 
regurgitant bruit is gencrallv blowing in cliaraelcr, whereas llic bruil ot inilral siciiosis is 



9t 



BRUITS, CARDIAC 



often rumbling. Early diastolic, mid-diastolic, and late diastolic bruits, occur also in 
mitral stenosis, but none of these should be mistaken for the bruit of aortic regurgitation, 
as the latter condition would be associated with hjpertrophy and dDatation of the left 
Ncntricle, the apex beat being displaced outwards and downwards, even to the sixth inter- 
costal space, and would be confirmed by the characteristic " water-hammer ' pulse. In 
mitral stenosis without mitral regurgitation there is very little displacement of the apex 
Ijeat, because the left \cntricle is not enlarged. The bruit of mitral stenosis is often 
associated with a presystolic thrill, whereas that of aortic regurgitation is not. 

In order to imderstand the various bruits which occur in mitral stenosis, the manner 
in which they are ])roduced must be discussed. They are caused by the blood being forced 
tlirough the stenosed mitral valves. The two forces which produce this are the contraction 
of the walls of the left auricle and of the right ventricle. The suction action of the left 
\entricle during its diastole is probably not sufficient in itself to cause the bruit, but simply 
helps in the work of the left auricle and right ventricle. The presystolic bruit of mitral 
stenosis occurs during the end of the ventricular diastole, and corresponds to the systole 



n n „iin 



D 



n 



D 



Mid-iUastolic bn 



D 



al steuosis fSiinyer's Physical .?/yn^). 



of the left auricle. A mid-diastolic bruit sometimes occurs in mitral stenosis. This may 
be the only bruit present, but there may be a presystolic bruit as well, resulting in two 
distinct bruits during the ventricular diastole. These two bruits may be fused into one 
when the contractions of the right ventricle and left auricle are vigorous. The mid-diastolic 
bruit is probably due to the previous contraction of the right ^•entricle increasing the blood 
pressure in the lungs and left auricle, and so forcing tiie blood through the stenosed mitral 
^'rtlve. It varies slightly in its situation in the ventricular diastole in different cases, but 
whether early or late it is always separate fi'om the previous second sound instead of 
replacing the latter in the way an aortic regurgitant murmur does. Wlien the force of the 
contractions of the left auricle begins to fail, or when there is aiiriciiifir fibriUaiion. as shown by 
total irregularity of the heart or by an electro-cardiogram {Fig. 196, p. 486). the presystolic 
bruit often disappears. In mitral stenosis there may therefore be a presystolic bruit, or a 
mid-diastolic bruit, or mid-diastolic and presystolic bruits, or a bruit which occupies almost 



BRUITS. t'ARDIAC 



95 



tlie whole of the ventiie.ilar diastole. With all these bruits the first sound at the apex is 
usually slapping or thumping in character. This alteration in the first sound may be 
present without any of the above-mentioned bruits, and is in itself very characteristic of 
mitral stenosis. In some cases the second sound is redu])licated at the cardiac apex, while 
in others— and this in the majority of the cases—it is inaudible. The pulmonary second 
.sound is accentuated or reduplicated. The bruit may be accompanied by a mitral systolic 
bruit, as regurgitation often occurs through the stenosed orifice. 

A presystolic bruit in the mitral area is usually due to mitral stenosis, but it also occurs 
without any mitral stenosis in some cases of aortic regur^Uaion or of dilatation of the left 
ventricle, when the bruit is spoken of as Flinfs murmur. To distinguish between the latter 
and the simUar bruit of actual mitral stenosis may be dilhcult : in an uncomplicated case 
of mitral stenosis the apex beat is normal in position, but when Flint's murmur is present 
the apex beat is displaced to the left on account of the enlargement of the left ventricle. 
The presence of aortic disease also points in the direction of the bruit being Flinfs murmur. 
This bruit is often considered to be caused by the vibration of the anterior curtain of the 
mitral valve as it lies between the regurgitating blood-stream through the aortic orifice 
and that flowing into the ventricle from the left auricle. If this were the true explanation. 
Flmt's murmur should f)ccur early in diastole instead of being presvstolic. Another view 
IS that the blood regurgitating through the aortic orifice lifts the anterior curtain of the 
mitral valve, and so obstructs the mitral orifice at the end of the ventricular diastole. 
Neither of these explanations seems to be sufficient to account for the murmur. In a 
normal heart the ratio of the diameter of the mitral opening to that of the left ventricle is 
about 1 to -2 : in mitral stenosis, on account of the contracted orifice, the ratio may be, say, 
i to 2, the size of the left ventricle remaining the same, and a presvstolic bruit occurs, iii 
aortic regurgitation, although the diameter of the mitral orifice remains the same, yet the 
diameter of the left ventricle is greatly increased on account of its dilatation. The ratio 
between the diameter of the mitral opening to that of the left ventricle might be. say, 1 to 4. 
or exactly the sjime ratio as occurs in mitral stenosis— a relative mitral stenosis when the 
size of the mitral opening is compared with that of the left ventricle. The one condition is 
merely on a larger scale than the other {Fig. 40) : and as the altered ratio of these two 
diameters produces in mitral stenosis a presystolic bruit, it is probable that the same ratio, 
although the factors are on a larger .scale, produces in aortic regurgitation a Flinfs murmur 
—which IS also presystolic in time. A presystolic bruit is sometimes present without any 
aortic reguigilalioii. and williout mitral stenosis, but always with an enlarged left ventricle ; 
and this seems to point to llic regurgitation of (he bloo.l Ihrough the aortic valves not 
taking any direct part in tlie production of the bruit. The followina diagrammatic draw- 
ings of Ihe h,.arl are eonMr„e|ed to show the prob-.l,!,. i,„„l,. ,,f production of Flinfs 
murmur : — 





Xormnl heart. 

Kiitio of rliametcr o( 

mitral vai\'es and dili- 

"ii'terot left ventricle, 

alioiit 1 to 'i. 



Mitral stenosis. 




II). IJiat-riim to e,v|iluici the origin of I'liiitH 



Dilated lert ventricle. 
Hat io 'about 1 to •! ; i.e. tlie same 
proportion as in mitral stenosb. 
I'nsystolic bniit (I'linfs). 
ur (.Sawyer's rittmfat si-nts\. 



but 



l)iasloli( 

it is pos 



liniit.N 
iblc Co 



are heard only vcr>' occasionally over other areas of I lie i.rcconi 
a pnsyslolic bruit to occur in llic Irieiispid region as the icsiilt 



96 BRUITS, CARDIAC 

tricuspid stenosis ; such a bruit is rarely ])resent witluiut valvular disease of the left side 
of the heart also. 

A functional bruit is never diastolic in rhythm ; but it is important to distinguish 
the niid-diastolic bruit of acute endocarditis from the similar bruit of fibrotic stenosis. 
Diu'ing endocarditis there is some thickening of the valve-flaps from inflammatory oedema, 
and this leads to bruits not unlike those of fibrous stenosis. The diagnosis depends u]3on 
(1) The development of the bruit under observation : if in a case of acute rehuniatism a 
mid-diastolic bruit is noticed to develop rapidly, it cannot be due to fibrosis, and must result 
from acute inflanmiation of the valve : (2) The course of the bruit : if it is due to fibrosis 
it will persist, if to endocarditis it will change with time, becoming less definite if the 
endocarditis resolves, more definite if the inflammation goes on to scarring and stenosis : 
(3) The age of the patient : mitral stenosis does not occur commonly before puberty, so 
that it is most risky to interpret a diastolic apical bruit in a child as being due to mitral 
stenosis. J. E. II. Snwijer. 

BULLy£. — A bulla is literally a water-bubble : it is synonymous with bleb or Ijlister ; 
it differs from a vesicle only in its size, which may be from half an inch in diameter to that 
of a tangerine orange or more. Almost any vesicular skin disease may be of bullous degree 
occasionally ; there are certain diseases in which bidla- are characteristic ; and there are 
yet other affections in wliich. although bulUe are not always present, they may occur 
sometimes in a marked degree. The following are the chief conditions under whicli bulla; 
are, or may be, a prominent featiu'c of the case : — 

A. Conditions in which Bullae .vre usual : — 

Pemphigus I Herpes gestationis I Pempliigus neonatorum 

Erythema biillosuni j lirythema iris Cheiropompholyx 

Dermatitis herpetiformis | P^pidermolysis bullosa | 

Local application of vesicants, sucli as cantharides, arnica, rhus toxicodendron, croton 
oil, nitric acid, scaldmg water, hot solids, or extreme cold, for instance after freezing 
with carbon dioxide snow. 

Local friction by splints after fractin-es ; or by boots, oars, tools, etc. 

li. Conditions in which Typical Bull.e >l\y occur, though they are not usual : 



Erysipelas 

Impetigo contagiosa 
lodism 
Bromidism 



Glanders 
Syphilis 
Syringomyelia 
Gangrene 



Frostbite 

Raynaud's disease 
Scurvv' 



Extreme oedema from Brighfs disease or heart failure 

Workers amongst turpentine, chrysarobin, varnish, aniline dyes, and other chemicals ; 
tar products, resin, volatile oils ; satin-wooil, primula obconica, and some other 
plant products. 

Poisoning by large doses of certain hypnotic drugs, notably veronal and acetanilido. 
especially towards the end of a fatal case. 

The diagnosis is sometimes obvious ; for instance, herpes gestationis — also known as 
hydroa gestationis, erythema gestationis, and dermatitis pruriginosa polymorpha recurrens 
graviditatis — is probable when a bullous erujjtion develops in a pregnant woman ; and the 
diagnosis is certain if there is a history of former pregnancies each associated with a similar 
eruption, with complete freedom from the complaint between the pregnancies. The eruption 
itself is precisely similar to that of dermatitis herpetiformis, described below, and there is 
generally eosinophilia (p. 99). In most cases the trouble begins in the later months of 
pregnancy, but tends to develop earlier in each successi\e ])riguancy : and whereas in most 
cases it suljsides rapidly when the child is born, in a few instances it may last into the |)iR'r- 
perium, or even develop only during that period. The most troublesome part of the com- 
plaint is the itching and irritation, that often amount to actual pain. A person subject tci 
pempliigus or erythema buUosum might develop an attack during pregnancy ; but herpes 
gestationis is excluded if recurrence takes place apart from pregnancy, whilst the occurrence 
of the bullous eruption solely in association with pregnancy makes the diagnosis obvious. 

Bnlhe in an infant generally receive the term pempliigus neoiKitnnnn, but the eruption 



BULL.??: 97 

is not related to ordinary pemphigus, so it is a pity the word pemphigus is employed at all. 
There are two distinet varieties, namely : (1) That in whieli the bullae are chiefly on the 
hands and feet, one of the manifestations of a severe and generally fatal type of congenital 
syphilis, in which the eruption appears almost immediately after birth instead of after an 
interval of days or weeks, as in other cases ; and (2) That in which there is an infection of 
the skin of the nature of impetigo — generally staphylococcal, but in some cases due to less 
usual organisms such as the liaciUus pyoajaneus — producing bulte instead of the more 
usual pustules ; the latter is an affection of poverty-stricken districts, occurring in more 
or less epidemic form, sometimes closely related to the practice of a particular midwife, 
and fortunately rare now-a-days. 

Clieimpunipholi/.r may generally be recognized at once. It is a dysidrosis, and the 
sweat-glands (jf the palms and soles are most affected, though those of the forehead, chest, 
and back, may sometimes be affected too. As a rule the sweat retained in the glands 
produces subcutaneous vesicles that are barely larger than sago grains ; as the superficial 
epidermis becomes worn off, the little sweat-cysts reach the surface, a process assisted by 
the scratching that usually results from the accompanying irritation. After each cyst 
bursts there is destiuamation which may simulate that of scarlatina. The malady occurs 
in summer weather, or in tropical climates, especially in those who perspire freely. 

Blisters produced by vesicants are diagnosed readily when it is known that any applica- 
tion is being used. Dilliculty arises mainly in two classes of persons, namely, (1) In those 
who live in houses ujion which the lihiis toxicndei}dron is grown as a Virginia creeper, the 
nature of the case being discovered usually from the fact that the patient is always affected 
when at home, and never when away : and (2; In hysterical patients, or in malingerers, 
who produce the skin eruption surreptitiously. If the latter is suspected, it is generally 
possible to place the patient imder conditions which preclude self-application, when the 
disappearance of lesions confirms the diagnosis ; or the actual vesicant employed may be 
discovered, liquor epispasticus for instance, or some other preparation of cantharides ; 
croton oil ; cajjsicum ; carbolic acid ; mylabris ; iodine ; or one of the strong mineral acids, 
especially nitric acid. 

The relationship of occupation to a bullous dermatosis may become obvious from the 
way the skin trouble recurs whenever any particular work is resinned ; the list above 
indicates the kind of occui)ations that are liable to produce it; nearly all these ]in>duce 
l)ull;e far more seldom tlian they do a vesicular dermatitis. 

Kxtremely (cilcniatous tissues are easily blistered, and on this account one must be 
chary of diagnosing anything l)ul simple l)lislers when bulla- develop upon o-dcmat(ius legs 
or other parts in assoeialion, for instance, with liii<iltt's disviisc, or in chronic licuii cases with 
failing eomjiensation. The same api)lies to the blebs arising on the skin oi fractured limbs, 
and also in the region of a local gaiigretie ; or necrosis of the soft parts due to such causes 
an frost-bile, or Hai/tiaiiil's disease, or scurvy. The diagnosis in these <'ases will nearly always 
be clear enough, and so will it be in eases of simple blisters due to friction. 

Having thus excluded the more obvious cases, there remain : pem])higus, erythema 
bullosimi. dermatitis lurpeliformis, erythema iris, epidermolysis bullosa, er\sipelas, impetigo 
contagiosa, iodism, bromism, glanders, syphilis, and syringomyelia. Of these, acquired 
typliilis is sD seldom bullous that it would not be diagnosed unless there was strong collateral 
evidence of the nature of the coiTiplaint. Syriiiiiomyelia is rare also, and bulhe occur in but 
a small proporlion ol the eases ; should they do so they would attract, attention from being 
eonlined Id a local ana. Ilie lingers and hands lor instance, leaving the rest (if Ihc peison 
free. The diagnosis would be conlirmed by linding cutaneous sensibilily natural, Ihough 
I lie patient cannot distinguish |)ain from touch, or heat from cold, in the airectcd (larts. 
Tlic cutaneous alTcctions of i-yringomyelia are known as .Morvan"s disease. The lesions 
arise because the skin is ins<nsili\ c lo Ihings lliat arc painlul iir ImiI enough lo pniduee 
sores and blisters. 

The palicnfs oceupalion may suggesi llie malady in a <asc of \>\i\\in\s liliniilers : a horse 
Willi uliicli Ihc palicnl had lo do mighl be known lo be aMecled wilh Ihe eoniplainl. The 
sUiii ciiiplion is sometimes ipiile a lale nianircslalion of a |)rolonged and obscure febrile 
illness when Ihe glanders inleelion has started internally, for instance in the lungs. The 
Hneilliis inidlci may be found in direcl smears tnini the contents of Ihc bnllii', or in cultures 
from Ihi'in. Ha<'tcriol(.gical methods alloid Ihc linal criterion of ylandcrs. 

1) r 



98 BULL^ 

Both bromides and iodides may ]3rodiice various types of skin eruptions. Tlie commonest 
is simple acne ; but there may l)e a patchy erythema with cutaneous infiltration or nodular 
swelling studded with yellow points from which thick puriform fluid can be expressed ; or a 
conHiient furuncular lesion ; or a true bullous erujition or hydroa. The latter is decidedly 
rare, but its occurrence should be borne in mind, and enquiry made as to aiiy drujjs thai 
the patient may be takinn ; in the case ol iodides the urine uives a bhiish-urcen colour with 
the guaiacum test, tliough no blood is present, and if there is still doubt a quantity of 
mine may be evaporated down, and either bromine or iodine detected by ordinary chemical 
tests. Bromide and iodide eruptions have been recorded in infants at the breast when the 
mother has been taking the drug without herself presenting any cutaneous symptoms. 

Bullous impcligo conlngiosa is a variety of impetigo. Fluid accunnilates in the infected 
spots so (piickly that at first it does not appear to be purulent, but rather to take the form 
of big vesicles or bulhc. These often become pustular, and as they dry up the crusts over 
them have a eharact eristic yellow honey-like appearance. The condition can be diagnosed. 
as a rule, from tlie fact that other parts of the body present the tj^sical lesions of ordinary 
imjjetigo ; there may be other patients affected in the same house or school, and the condi- 
tion is as readily curable by antiseptic measures as is impetigo. There is a very rare and 
extremely grave disease described as impetigo herpetiformis in pregnant women ; but this 
seems to be an aggravated form of dermatitis herpetiformis or herpes gestationis become 
piuiilent and contagious. It is found in Austria, but not, apparently, in England. 

Erysipelas is a familiar cause of bulla>, and when blebs are present upon the typical 
tender, slightly raised, and well demarcated red skin at the height of the affection, in associa- 
tion with the constitutional symptoms and pjTexia, there can seldom be diilicidty in the 
diagnosis. It is when the erysipelas is subsiding or has subsided, whilst the bulla?, or the 
remains of them, are still obvious, that difficulty might arise. Streptococci may be detected 
bacteriologically . 

If all the above conditions can be excluded, and the ])atient is suffering from a disease 
of which bulte with more or less erythema are the chief manifestation, tlien the diagnosis 
has been naiTOwed down to one or other of the following : pemphigus, erythema bullosum, 
dermatitis herpetiformis, erythema iris. aTid epidermolysis bullosa : there is evidence to 
show that these are closely related in some respects, the different names applying to affec- 
tions that differ more in type than kind. If the patient develops bulla- on various parts of 
the trunk and limbs without any erythema, or at any rate without any erythema imtil the 
bulla' have been present a longer or shorter time, the condition is described as pempliigns. 
If the bulla> develop, not on normal-looking skin, but upon places v.here there has already 
been cr>thema, associated with more or less itching, or even pain, before the buIUe develo]), 
and if the whole eruption consists of this combined condition of erythema and large bulla-, 
the name used to designate it is enjtliema lidlosiim. If the bulhc tend to dry up at their 
central parts and then to be followed by a secondary ring of vesicles or blebs aroimd the 
original one, these secondary vesicles being followed in turn by others upon a yet larger 
ring outside them, the condition is referred to as herpes iris or as erythenia iris, according 
as there is little or much erythema before the first vesicles or bulla? a])])ear. ^Vhen the 
bullae are apt to develop on any part of the body from a degree of rubbing or scratching 
whicli in the ordinary individual would be quite unlikely to produce blisters, this imdue 
tendency to blister formation from what ought to be inade(iuate causes is spoken of as 
epidermolysis bullosa, a condition which may persist throughout life without necessarily 
leading to any other untowai'd symptoms ; it is probably related to factitious urticaria. 
Dermatitis herpetiformis is a polymorphous eruption, of which bulhc form but a part ; the 
trouble begins with itching of the skin, and more or less general disturbance, part of which 
arises from the loss of sleep entailed by the irritation. In various parts of the body or limbs 
erythematous and urticarial patches supervene, some of which subside without furthei' 
development, whilst ujion others clusters of vesicles soon appear. Many of the clusters 
contain twenty or thirty vesicles upon a single inflamed base ; some, fewer vesicles of larger 
size ; others develop into typical blebs varying in aiea from that of a sixpence to that of a 
half-crown. No region of the body is exeinj)t. The characters of the lesion are precisely 
similar to those found in pregnant women sufiering from herpes gestationis, but there 
nuist be a difference in causation, for the latter, though it occurs with every successive preg- 
nancy in the same woman, remains in complete abeyance between the pregnancies, whilst 



CACHEXIA 99 

dermatitis herpetiformis — Diihring's disease or hydroa — may occur in either sex and at 
almost any age, tlioiigh it is less common in cliildren than in adults. It is probably due 
to the action of some poison circulating in the blood, derived perhaps from the food in 
some cases ; it is possible for two persons to be taken ill after partaking of the same 
food, one with acute gastro-intestinal symptoms, such as diarrha-a and vomiting ; the 
other with acute pem])higus ; it looks, therefore, as if pemphigus and its allies may be 
related to the acute urticaria that is so familiar in certain cases of shell-fish poisoning. 

.\ny one of the bullous dermatoses may be either acute, subacute, or chronic ; in any 
of these degrees there may be practically no constitutional disturbance on the one hand, or 
the patient may be so ill with pyrexia and anorexia as to require to stay in bed ; not a few 
such, cases prove fatal. In all the bullous dermatoses the eru])tion may be restricted to 
the cutaneous surface ; but the bulte may also occur upon mucous membranes, especially 
of the mouth, palate, a»sophagus, nose, colon, rectum, and vagina. Even when temporary 
recovery has taken place there is a tendency for subsequent attacks to occur. There is 
also a tendency to ha-matoporphyrinuria during the exacerbations. 

Finally, it may be emphasized that although it is often stated as a general rule that 
many skin diseases may be associated with eosino])hilia, as a matter of fact few skin diseases 
other than the bullous dermatoses produce any marked degree of eosinophilia, so that a 
flifferential leucocyte count may afford valuable diagnostic evidence. The absence of 
eosinophilia by no means excludes pemphigus or erythema bullosum or any other bullous 
dermatosis, but the presence of eosinophilia in a doubtful case increases the probability of 
the condition being one of these : it is noteworthy that whereas eosinophile cells may 
abound in the contents of the natural bulla', those which occur in a blister produced artifi- 
cially in the same case present no such eosinophilia. Ucrberl French. 

BUZZING IN THE EARS.~(See Tinnitus, p. 7'->2.) 

CACHEXIA literally means " a bad habit,' and is an ill-defined term used to include 
almost any depraved condition of the body in which nutrition everywhere is defective. It 
is generally applied to patients who exhibit at the same time progressive loss of weight, and 
change of complexion iu the direction of sallowness or actual an;cmia. (See Wkioht, Loss 
OF, p. 7(iH : and .An.kmia, p. 20.) The word is generally prefixed by a qualifying adjective, 
such as cancerous, syphilitic, maUirial. tuberculous cachexia, the diagnosis being indicated by 
other symptoms or by the history. Other varieties of cachexia that may be given special 
mention, and which, if they are borne in mind, are not as a rule difficult of diagnosis, are 
C. splcniiii. including blood diseases such as leucocythcmia. in which with progressive loss of 
weight and amemia there is enlargement of the Si-i.i:kn (p. (i2H) ; C. ulcrinn. from chronic 
non-fatal lesions of the uterus or other jjclvic organs, notably loienrrlioa, clininic endo- 
metritis, or fibroid tumours ; and often accom])aiiicd by brown disfiguring |)igmciilation 
(chloasma uterinum), especially on llic rorchead and round the eyes ; C. pfiriisilicd. due to 
infection by the n)ore serious irilcsl iiial or other i)arasitcs, especially Aukyloslouiuin duo- 
ilruiilv. Ilothriorcjihiilus lulus. Hilhiiriiu iKrinulohia. and Trichino spiralis : (.'. rhliiri)licii. a 
synonym for chlorosis : ('. mcrruriulis. attributed to the cllecls of mercury, though perhaps 
reails due to the syphilis for which the mercury has been given; ('. croplilluihiiicii. sonie- 
tiriics associated with (Jraves's disease ; C. palustris, or marsh cachexia, iluc cillicr to actual 
malaria or to constant living in unhealthy, damp surroundings ; C. alkaliuu. 1 he hail health 
caused by taking large (luantities of alkalies for a long jjcriod, and evidenc<il by pallor, 
breathlessness, emaciation, and anu^mia ; ('. a<piosa, also calle<l pica, and (.'. africuna. a 
term given to an aiKcmic condition leading to serous effusion, and often accompanied by 
l)erversion of appetite, seen in hot climales and especially among negroes : it has recei\ed 
many names, such as white tongue, stomach disease of negroes, negro cachexy, intratropical 
ana'inia, dirt-eating disease ; doubtless many different disorders ha\e been included under 
this name, including the results of malaria or of intestinal worms : ('. rcualis. which results 
from piolongcd albuminuria, espceiali\- in subacute tubal nephritis; ('. scorbutica, a con- 
dition formerly descrilied as a-.sociated with rickets, though more likely related to the 
inlaiilile scurxy ol Harlow, nutrition being impaired, the head and upper pjut of the body 
p( rspirini; pniliisrly during slee|), ana'inlii developing, and the ])atient l)e;ng intolerant of 
bcil-clolhcs iiwiii;; l(i tenderness or actual palnfulness of the bones from subperiosteal ha'inor- 
rhag(•^ ; there may or may not be bleeding <,'ums ; C. saluruiua, from ehiiinie lead poisoning. 

Herbert French. 



100 CA:MMir)(iES PANCREATIC REACTION 

CAMMIDGE'S PANCREATIC REACTION.— The improved pancreatic reaction 
depends upon tlie laet tliat wlien tlie mine of a patient suffering from pancreatic inflamma- 
tion is liydrolysed by boiling with dilute H C'l, a substance having the reactions of a pentose 
is set free, and may be recognized by conversion into its osazone crystals by treatment 
with phenylhydrazine, a golden yellow floccident deposit of flexible hairlike crystals forms, 
arranged in microscopic sheaves, readily soluble in dilute sulphuric acid. The appearance 
and solubility of the crystals are very characteristic, but as glycuronic acid, which is set 
free to a greater or less extent in all urines during the hydrolytic ])rocess, also forms a crystal- 
line compound with phenylhydrazine, it is removed by treating the still acid urine witli 
tribasic lead acetate, after the excess of hydrochloric acid has been neutralized with lead 
carbonate. The lead that goes into solution has also to be removed by converting it into 
an insoluble sul])hide or sulphate before the phenylhydrazine lest is applied. 

The resuhs of cHnical experience and many animal cxixriments have demonstrated 
that a positive "pancreatic' reaction is strong presumpti\e evidence of a disturbance of 
fiuiction and of active degenerative changes in the pancreas. In most cases these are 
consequent on inflammation, either acute or chronic, but in a few instances a positive 
reaction seems to rise from abnormal physiological activity. The latter may, however, be 
neglected for all practical purposes, for it is not associated with symptoms suggestive of 
pancreatic disease. 

It has been pointed out repeatedly that the pancreatic reaction is not pathognomonic 
of pancreatitis, and the writer must again insist that the residts of the test must be con- 
sidered in conjunction with the clinical symptoms and the evidence to be obtained by a 
complete analysis of the urine and faeces. By doing so one can not only obtain confirmation 
of the indications given by tins s])ecial method of examination, but also infer the probable 
cause of the changes in the |)ancreas. which is a most important point, for pancreatitis is 
rarely, or never, a primary disorder, but is usually secondaiy to an ascending catarrh from 
the duodenum, gall-stones in the common bile-duct or in the ampulla of Vater, invasion of 
I he pancreas by a duodenal or gastric ulcer, malignant disease either primary in the pancreas 
or secondary to some other organ, back-pressure from disease of the heart or lungs, arterio- 
sclerosis, alcoholism and cirrhosis of the liver, syphilis, tubercle, influenza, tyjshoid fe\er. 
nuunps, etc., etc. In many of these the clinical signs and symptoms alone are sufficient to 
indicate the cause of the pancreatitis, but in others they are so indefinite or obscure that it 
is only by considering the results of a complete quantitative and qualitative analysis of the 
urine, and fa;ces also, that a correct diagnosis can be arrived at. 

A single negative pancreatic reaction does not exclude chronic pancreatitis, or rather 
the results of inlliimmation of the pancreas, for the reaction is only given when there are 
active degen( valivc changes in the gland at the time when the urine is being excreted. 
Cirrhosis of tlie i)ancreas due to j)ast iuHammation does not, therefore, cause a reaction after 
the inflanuiiiition has subsided. Cancer of the pancreas too is associated with a positive 
reaction in only about 25 per cent of cases, the presence of the growth being apparently 
unattended by any inflannnatory changes in the pancreas in the remaining 75 per cent. 

As the ordinary method of carrying out the test is interfered with by the presence 
of sugar in the urine, a modification, in which a hydrochloric acid solution of the j)recipi- 
tated lead salt from the basic lead acetate solution is submitted to steam distillation, has. 
been devised (Cammidge, Glycosuria and Allied Conditions, p. 274). The quantity of fur- 
furaldehyde formed is determined by treating the distillate with sodiiun nitrite and then 
titrating with iodine solution. This method, which can also be used for sugar-free lu'ines, 
gives <|uantitative residts by whicli one case can be com|iarcd with another, and the course 
of any one be followed accurately. Numerous ex])crimciits luive shown that the " iodine 
coellicient ' of normal urines is nil, and that even when simple digestive and hepatic disturb- 
ances are present it rarely exceeds 10 to 1-5 per cent. When there is inllammation of the 
pancreas the iodine coellicient rises to ten, twenty, or more per cent, with a total for tlu' 
twenty-four hours urine of lOO. 200. or over. As one would expect from the (|iialitati%e 
test, many cases of cancer of the ])aiicrcas give a negative iodine coellicient. Init in some 
25 per cent similar readings to those obtained in cases of pancreatitis are obtained. 

Other points to be noticed in examining the urine from suspected cases of pancreatic 
disease are : — 

1. The presence of calcium oxalate crystals (see Oxalubia, p. 42:5) in the centri- 



CAMMIDGES PAXCKEATR' REACTION 101 

fugalized deposit ; these are met with in 63 per cent of cases of chronic pancreatitis, or 
73 jjer cent if jaundiced cases are excluded. 

2. A pathological excess of urobilin (see Plate A'A'A'il', Fig. VI. p. 748) ; this is a very 
constant indication of cholangitis, and a particularly useful sign of gall-stones in the 
common bile-duct, whether acconi|)anied by jaundice or not. 

3. A well-marked indican reaction : pointing to a catarrhal coudition of the intestinal 
mucous membrane, with abnormal putrefactive changes in the contents of the intestine, 
and possibly a duodenal or gastric ulcer. 

4. Bile pigment in the urine : showing that there is some obstruction to the free flow 
of bile into the intestine, due to impacted gall-stones, gripping of the common bile-duct by 
the inflamed head of the pancreas which surrounds the duct in 62 per cent of cases, 
malignant disease of the head of the pancreas, or a growth in the common bile-duct. 

For the purposes of a further differential diagnosis, the results of a qualitative and 
<iuantitative analysis of the fa?ces are most important. In carrying out the analysis the 
points to be noticed particularly are : — 

1 . The presence or absence of stercobilin : in gall-stone obstruction, traces at least are 
nearly always met with, whereas in malignant disease of the head of the pancreas total 
blocking of the duct is the rule, although the soft growths occurring primarily in the 
coninion duet usually allow some bile to (ilter through so that traces of stercobilin are met 
witli in the f.Tccs. 

2. The percentage of unabsorbed fat : in cancer of the pancreas this is always very higli, 
70 to 80 per cent ; it is usually somewhat less in growths of the common duct, averaging 
60 to 70 per cent, and varies from a subnormal percentage in early catarrh of the pancreas to 
as much as 50 or, rarely, even 80 per cent in advanced chronic pancreatitis. 

3. More important still, however, is the relation of the ■ unsaponiflcd ' to the ' saponi- 
fied fals,' for whereas the former are in excess in diseases that interfere with the digestive 
functions of the i)ancreas, such as cancer of the gland and advanced chronic |iancreatitis, 
the latter i)redominate in obstruction of the connnon duct by gall-stones, without pan- 
creatitis, and in malignant growths not involving the pancreas. It must be borne in mind, 
however, that, owing to the abnormal activity of fat-splitting bacteria in the lower bowel, 
such as is met with in some cases of intestinal catarrh, an excess of sai)onilied fat may be 
found in cases of chronic pancreatitis where the disease is due to an infection sjjreading 
from the duodenum along the pancreatic ducts. A similar excess is often met with in early 
catarrhal pancreatitis, owing probably to an increased flow of ijanercatie Juice analogous to 
the salivation met with in ])arotitis. 

4. .Microscoi)ieal examination of the faeces for fat globules, fatty acid crystals, undi- 
gestcfl muscle fibres, and coimcctive tissue, should not be omitted : a large excess of fat 
globules and free fatty acid crystals, with numerous isolated undigested muscle fibres, 
pointing to cancer of the pancreas or advanced cirrliosis of the gland, whereas nnisele 
associated with comieetive tissue points to defective gastric digestion. 

.">. .\n acid reaction of the fresh stool is in favour of a diagnosis of pancreatic disease ; 
in simple gall-stone obstruction, the fii-ces are usually alkaline. 

6. Occujt blood, when constantly present in the faeces (see j). 81). is suggestive of 
malignant disease or. more rarely, advanced pancreatitis, in which it is now well known 
that there is a Imrnorrhagic tendency ; while the discovery of blood intermittently points to 
a gastric or duodenal ulcer, which may be invading tlic pancreas and setting up paiicrcalitis. 

15y carefully considering all the facts thus obtained, and inter|)reling lliem in the light 
of the clinical signs and symptoms, it is possible, not only to diagnose correctly the existence 
of disease of the pancreas, but also to arrive at a satisfactory conclusion as to its probable 
cause. .MTection of the pancreas is much conunoner than is generally supposed, and many 
trying cases of chronic indigestion, recurring or pc isisleril jiumdice. and ohscun- afl'eetions 
of the upper abdomen would be explained, and satisfactorily treated, if investigated as 
above. I nclia-noscd. and coiiscciuiril l\ iiiihcalcd, |)ancrcatitis is probablv the most 
conunon , ausc ol ilialMlcs II Ibis w, ic iiimv wi<lrlv recognized much might' be done to 
stay the lurlhri- JTicnasc of that disease. ,. ., r,/mw/</.'c. 

CARDIAC BRUITS. -(See Huiirs, (Ain.rA.'. p. 8<t.) 

CARDIAC IMPULSE DISPLACED. (See IIkvmt Imci i.m;. I)ps,.|.s,r,n. p. -J!!?.) 



102 CHARCOT-LEVDEX CRYSTALS 

CARDIAC THRILLS.— (See Tiimixs, Phecoudiai,, p. 720.) 
CASTS IN THE URINE.— (See Albuminuria, p. G.) 
CEPHALALGIA. (Sec IIi-.adachf.. p. 293.) 

CHARCOT-LEYDEN CRYSTALS were at one time .sujiposed to consist of sperniin. 
but now there is considerable doul)t as to their exact chemical nature. Their chief import- 
ance from a clinical point of view is that they are more common in certain conditions than 
in others. They may be found either in the sputum, the blood, or in the stools. They need 
the higli jjower for their detection. Each resembles an elongated diamond witli clear-cut 
edges, without colour, but with a slightly yellow appearance when seen obliquely. They 
stain with eosin, and are soluble in hot water, in mineral acids, and in alkalies, so that for 
their detection a fresh specimen is required. 

In the sputum, they are commoner in ustlnna than under any other circumstances — 
true spasmodic asthma, such as also gives rise to Curschm.\nn's Spiral.s (p. 153), and eosino- 
jihile corpuscles in the s])utum. In determining whether a given ease is one of paroxysmal 
dyspnoea, cough, or bronchitis on the one hand, or true asthma complicated by bronchitis 
upon the other, numbers of Charcot-Leyden crystals in a fresh specimen of sputimi are 
evidence in favour of the latter. Small numbers of the crystals may be found in broncJiitis 
and in association with bronchiectii.iis. Init in true astlinia their numbers may be quite large. 

The occurrence of Charcot-Leyden crystals in the blood is of little diagnostic value. 
They are seldom found in fresh blood : but when the latter has stood for some time in bulk 
they develop, particularly in leukwniid. Some have tried to draw important clinical deduc- 
tions from the development of these crystals in blood, but it is doubtful whether they really 
have any significance of value. 

In the stools. Charcot-Leyden crystals have been found in a great variety of diseases, 
but whether or not clinical deductions can be drawn from their presence is doubtful. It 
is stated that, when they abound, the patient is probably suffering from an animal parasite : 
but it affords no indication of the nature of the parasite present. Their occurrence .should 
lead one to examine the faeces for parasites or their ova with even greater care than usual. 

Herbert French. 

CHEST, BLOODY EFFUSION IN.— When, on needling a pleural cavity containing 
fluid, tliis fluid is l()un<l to be obviously blood-stained, the fact is suggestive of one of three 
things : either the pleurisy has been exceedingly acute : or the chest lias already been 
ta|>ped not long jireviously, so that there has been h;emorrliage into the residual fluid ; 
or there is malignant disease of the pleura. 

The history of the ease may at once indicate whether the inflammation is very acute 
or not : the symptoms would have been of short duration, with much ))yrexia, whilst the 
fluid itseir would be of high speeiflc gravity, would contain a large amount of albumin, 
would probably coagulate spontaneously, and microscopically would exhibit numerous 
I3olynior|jlionuclear cells and lymphocytes, and abundant red corpuscles, but no jjartieles 
of growth in the centrifugalized deposit. 

If lilood is found in pleuritic fluid at a second tapjiing. when it was not present at the 
lirst, the fact is by itself of little value in differential diagnosis, for the bleeding has prob- 
ably been caused by the act of ])araeentesis. 

M'hen there is a new growth, and the effusion contains obvious blood at a first tapping, 
it is likely that the symptoms will lia\e been of gradual onset, without marked pyrexia ; 
the diagnosis is sometimes cleared up by finding fragments of new growth in the centri- 
fugalized deposit. It is of course by no means every case of malignant disease affecting 
the pleur.T that produces a blood-stained effusion ; but when the effusion is blood-stained at 
a first tapping, in a case that has not run a very acute course, one should be very .susjiicious 
of new growth. In not a few such cases there have also been com]3aratively large luinibers 
of coarsely granular eosinophile corpuscles in the effusion. It is often impossible to be sure 
of the diagnosis until tiie progress of the case has been watched, sometimes for weeks : |)leural 
eflusion, like that of a sini))le case, may be the only sign for a long time, but sooner or later 
one will expect to find evidence of obstruction to a bronchus or to the superior vena ca\a as 
the growth spreads in the mediastiiiuni, and occasionally the peculiarity of the shadows 
seen with the .r-rays point to the nature of the case {Fig. 42, p, 10.5,) Ilerlierl French. 



CHEST. PUS IN 



CHEST, DEFORMITY OF.— (See Deformity of the Chest, p. 166.) 
CHEST, PAIN IN.— (.See Pain in the Chest, p. UM.) 

CHEST, PUS IN. — When, on needling the chest, pus wells up into the exploring sj-ringe, 
it is )}i(ih;ible tluit the jiatient has an empyema. Other lesions may simulate empyema, 
howevei'. and e\ en when empyema is actually present it is important not to let the diagnosis 
rest at that : but rather to regard it as a symptom and try to diagnose its cause. It by no 
means follows, of course, that when the exploring syringe fails to detect pus, an empyema 
is not present, for sometimes it is situated either between the lower lobe and the dia- 
phragm, in front of the lung or between the lobes, or in some other position in which it 
is dillicult to Iiit it off with the needle. When pus is found but the amount is only quite 
small, there may be doubt as to whether it came from an empyema outside the lung, from a 
bronchus, or an (ihsees.s cfwilij in Ihe lung siihstanee. The nature of the case may remain 
undecided until a subsetiuent puncture, or a resection of a rib, conclusively discovers intra- 
pleural pus. Even when pus wells up in the exploring syringe, it is possible to mistake for 
empyema a collection of pus which is below the diaphragm. A subdiaphragmatic abscess 
and an abscess xvilhin llie liver are the two conditions most liable to simulate empyema in 
this way. If. however, the history, the symjitonis. and the iiliysical signs do not serve to 
distinguish between these dilferent 
conditions, it will still be clearly 
necessary to evacuate the ])us. 
and the surgeon's finger inserted 
through the wound will be able 
to feel whether the dia])hragm is 
above or below the collection. 
Even then there is one possible 
source of error, namely, when there 
is ])us both above and below the 
diaphragm. A subdiaphragmntic 
abscess, secondary perhaps to 
appendicitis upon the right side. 
or to a leaking gastric ulcei- U|)(>n 
the left, may ha\e infccttd the 
pleura through th<' diaphragm, 
causing first a serous and then a 
purulent effusion, separated Iroin 
that below the diaphragm merely 
by the thickness of tliat muscle. 
It may be very dillicult indeed to 
be sure of this condition, inch :it 
rilily cleared up until, when our 
abnormal pljysieal signs persist, and a sei 
plinigni as the case may be. is found at a sul 
eonsidcrablc assisliuicc sometimes in showin 
1)1- bcldw il. 

11. howiNcr. Ihe physical signs, symptoms, and the result of needling, all pn>\c con- 
clusively llial the eliesi contains Mil empyema, it is still necessary to deci<le as far as possible 
the iialiin- ol' Ihi- lallrr. Its (iiiiiinoiiest cause is pneumococcal infection, nearly always 
precede<l by lobar pncimioiiia in ailiilts. in children sometimes by bronchopnetimonia, but 
not iril're(pieritl\ arising iiisiilidiisly. It is probable that many of Ihe so-called latent 
enipyeniala of cliildicn have really been ipicceded by imdiagnoscd broiieliopiieumonia. 
l)iHieiilt\- oUcii arises from the fact lliat the iinioiinl ol' pus prrseiil is not Lircal. so tlial 
coiniircsses the lung siiHicienllv tn iiiiihr llic :il\i(ili iiirliss, llir hmiicliial liilics 
ill p.-ileiit. and there is no complete iliillness al Hie base or wliercNcr Hie empyema 
and over the alfeeted area lliire may be broneluMl bi 
r the alisenee ol' lireatli-somi(ls and of voice-sound' 
in adults. It llieic is doiilil as to the nature of the 




J-,.j:jl.~'-k,: 



l.i.thi 



IIh 



pus 



peration, the nature of the case not being 
intaining cavities has been evacuated, the 
collection of pus, above or below the dia- 
■(pienl exploration. The .c-rays may be of 
whether the diaphragm is above the |)us 



thoiiMl, 
still nil 
■ nay Ik 
instead 
einpyei 



ilhiiiL 



iiipy. 



and erai 
usually a 
iia MS jiiii 



inpanies 
I bv the 



104 CHEST, PUS IN 

liistory, bacteriological examination of the pus will often inciieate its origin. The com- 
monest organisms to be found are ])neiunoc()cei. streptococci, and staphylococci, though 
Bacillus coll communis, tyishoid bacilli, and the Bnciltus pi/oci/oiieus also occur, and e\eu 
other organisms may be i)rescnt in some instances. The mode of infection is generally 
either via the hnig, or from beneath the dia])hragm ; and careful intjuiry into the history 
and symptoms will generally indicate which of these two paths has been the more likely. 
When infection from any j)eritoneal condition such as appendicitis, leaking gastric or duo- 
denal ulcer, infected gall-bladder, or sub-diaphragmatic, perinephric, or hepatic abscess, 
can be excluded, when there has been no injury to the chest with broken rib, or a wound 
communicating with the exterior, and when there is nothing to indicate whether the infec- 
tion has succeeded janeumonia or is itself pneumococcal, suspicion will arise that the patient 
has been suffering from phthisis, whicli has caused a pleinisy which was at first non -purulent, 
but which became converted into an empyema as the result of secondary infection with 
pyogenic organisms, especially if there is a tuberculous family history, or if the patient has 
himself been weakly for some time. The sputum should be examined with ]3articular care, 
and K-ray examination is often Iieljiful ; for even when the compression of the lung by 
empyema has led to marked opacity at the base, it may still be possible to make out that 
apical mottling which is almost pathognomonic of phthisis (Fig. 41). 

Rarer causes of empyema than those mentioned above will generally have been 
accompanied by other symptoms, or by a history which suggests the nature of the 
individual case. Herbert French. 

CHEST, SEROUS EFFUSION IN.— When exploratory needling of the chest dis- 
covers clear serous lluid in the pleural ca\ity. it is important to regard the fact merely as a 
symptom, for there are many different causes to which it may be due, and. whenever possible, 
one should decide what is the actual cause in each particular case. In the iirst place, the 
effusion may be either inflammatory or merely a transudate ; the pleuritic must be distin- 
guished from the pleurnl effusion, t'linical points indicating that the effusion is inllani- 
matory rather than passi\e would be : its being unilateral, not bilateral and symmetrical : 
and the non-existence of the more common causes for passive effusion, ]5articularly chronic 
heart failure or nejihritis with general anasarca^ Physical, chemical, and microscopical 
analyses of the fluid may also serve to indicate whether the effusion was active or passive 
(see Ascites, \>. 48). There arc cases, of course, in which there may be doubt, but it is 
generally easy to determine whether the efliision is due to pleurisy or not. Pleural effusions 
not due to pleurisy occur late, and the diagnosis will have been made already from the 
existence of prominent symptoms earlier in the disease, for instance. Ai.bu.minuria (p. 4), 
Orthopncea (]>. 41S). (Kdi.ma (j). 411). and so forth. 

Pleuritic effusion, on tlie other hand, may be the Iirst and most prominent symptom 
ill the case, and it is not always easy to determine its cause. It should be an invariable 
rule to have the effusion examined microscopically, both for cells and for micro-organisms, 
and sometimes to have guinea-pigs injected with it in order to see whether in six weeks' 
time the inoculated animals have developed general tuberculosis. The commonest cause 
for apparently idiopathic ])leuritic effusion is latent or undiagnosed tuberculosis of the lung : 
there may be no sputum : ,>-ray shadows may be indctirniinate ; there may be no abnormal 
apical phy.sical signs ; there may be too few bacilli for them to be detected on direct examin- 
ation of the deposit, even when it has been most carefully centrifugalized, and yet inocu- 
lated guinea-pigs may develop typical tuberculosis and thus indicate the nature of the 
(ileiuisv. 

hitrutliDracic ne w gro ivth. wlutlur of the niediastimnn. lung, or (ileura, is fortunately 
uncommon ; but whenTt occurs, the symptoms and physical signs to which it gives rise 
are often very difficult to interpret. The growth may obstruct a bronchus and give all the 
physical signs of fibroid lung, with or without bronchiectasis ; it may cause a big mass, 
bodily displacing the hmgs and heart : it may cause multiple nodules which, unless they 
obstruct the superior ^•ena ca^'a and produce obvious varicose veins on the chest wall may 
give rise to no very definite signs or sym])toms at all : or, what is not at all infrequent, the 
growth may lead to jjleuritic effusion which may at first seem to be simple, or even be taken 
to be tuberculous, growth not being suspected until the rapid reciuTcnce of the effusion, 
repeated tappings, and rai)id downhill course of the disease ultimately suggest its nature. 



CHEST. SEROUS EFFUSION IX 



105 



Microscopical examination of the ccntrifugalized deposit of the pleuritic fluid sometimes 
leads to the detection of particles of new growth which clinch the diagnosis, whilst if the 
fluid in a case which is not absolutely acute is blood-stained at a first tapping, this by itself 
is highly suggestive of neojilasm (p. 102). The a;-rays often assist materially in making 
the diagnosis (Fia. 42). 

.Iriilr rliciniifitisni is a common cause of pleurisy with effusion, particularly between the 
ages of fi\e and twenty-. It may occur when there have already been joint-]5ains, or other 
symptoms of acute rheumatism, such as chorea, recurrent tonsillitis, pericarditis, endo- 
carditis followed by valvidar disease, skin affections such as erythema multiforme, erythema 
nodosum, peliosis rheumatica, or subcutaneous nodides. In such cases the diagnosis is not 
diflicult ; it is less easy when the pleuritic eflusion is itself the main symptom. The youth 
of the patient, the absence of anaemia or of ])revious ill-health, the absence of abnormal 
apical lung signs, of a family history of ])hthisis. the presence of a cardiac bruit, tlie occur- 
rence of heart disease, acute rheumatism, or chorea in other members of the same family, 
the rapid onset of the disease, and the almost equally rapid resolution of the eflusion. are 
points in fa\our of acute rheu- 
matism rather than tuberculosis. 
^Vhen in doubt, the ncgatixe results 
of guinea - pig inoculation would 
point in the same direction, and 
von Pirquet's skin reaction would 
be negative. There are. however, 
many cases of pleuritic effusion in 
young |)eo])le. in wlioiii it is inqjos- 
siblc to allocate llic cause cither to 
rheumatism or plilliisis. and such 
cases arc sometimes s|)ok{ii of as 
'simple"; doubtless most of these 
are either tuberculous or rheumatic, 
many ultimately jiroving to he the 
former. 

Pneumococcal lesions ol I lie 
lung generally ])roducc pleurisy : 
lohnr piiiiiDiiiiiiii indeed, ncxcr 
occiu-s uillHJUl il. |Iiiiml;Ii IiiidkIki- 
ptiriiniiiiiiii. even when il is pncu- 
tiKieoccal. often <l(ies. It is also 
possibU' for pncuniococeal |)leurilic 
effusion to occur without definite 
lobar pneumonia or bi'onchopneu- 
inonia preceding il primary pneu- 
mococcal pleurisy. I he diagnosis bcin 
fluid. It is dillieult to say whcic 
pneumococcal enqiyenia bc'giiis. W,. 
case often exhibiling clear lluid at 
pus Inter still. 

lirifilil's iliscdsv niii\ <'ausc eillicr a passive eriMsioii rriini liciul Iniliirc ill elirdiiic eases, 
or simple aceiMnulalion ol' tederna lluid in the pleural cavities without heart lailuic in cases 
in which the general iiilema ol Urighls disease is extreme : or actual pleurisy with serous 
effusion, probahly the result of intircurrent inhclion by some organism, corresponding 
with the peritonitis with .Ascrrios (p. 4:5) and the |)ericarditis that may also occur in these 
cases. 'I"he diagnosis will be indicated by the .Ai.nr.MiMHiA (p. 4). Jissociatcd with renal 
tube-casts : and if there is bilateral effusion without universal (cdcma. but with signs of 
heart laihuc in the I'orm ol orthopiKca. <c(lema of the legs, and |)erhaps ascites, the cliiision 
is |)assjve : it hclongs to the second <'ategory if there is universal (i<lema ; whilst ii (he 
effusion is inllanunalory it will probably be unilateral, or else more miukerl in one side of Ihc 
chest (hitii in the other. In a few cases .-ui extensi\i- pleuritic ellusion in a middle-ageil or 
eldi-rly person is the llrsi indiealion lli:il llieii' is ini\ lliing reiiiil Hie in.ilhr, I he diagnosis of 




Kis;lit 



Left 



Fig. 42.— Skiii^ram slio«-iii2 sarcoma of the right hmf: 
seeonUary to sarcoma of a kidney. Tlie patient was a child, xuicd 
n years" GG. .Ma.sscs of new uro'wth. H. He.-irt. TIic lower mark 
G point« in the rlirection of the lower ma-ss ol growtli. but the lino 
h:us not been prolonged so far iis to the shadow of the growth 

(Hkiiujmm hij Dr. C. Thnrsliin r!nl/„ii,l.) 



X coiiliriiHil liy Hie 
piieiiiMoeoeeal sen 



■oNcry ol' piieiuiKieneei in llic 
enusion stops, howe\er. and 
o merging into one another, and the same 
cNploralioii. eloudv lluid a few davs later, and 



106 CHEST, SEROUS EFFUSION IN 

red oramiliir contracted kidney being confirmed by the urinary changes, big heart, ringing 
aortic second sound, high blood-pressure, or by albuminuric retinitis. 

Any of the severe blood diseases, particularly Hodgkin's disease, lympliadenoma, leu- 
kinnia, splenic anceniia. j)seiido-leuk(emin infantum, and to a less extent pernicious ancemia, 
may give rise to inflammation of any of the serous membranes, and thus lead to ascites, 
pericarditis, or pleurisy with effusion. The latter is seldom an early sym])tom in such cases, 
however, and the diagnosis will generally be known already from the presence of ])ronounced 
An.«;mia (j). 20), enlargement of the Ly.aiphatic Gl.vnds (p. 376), or enlargement of the 
.Spleen (p. 628), with or without pathognomonic blood-changes already discussed under 
these various headings. 

Pleuritic effusion may sometimes be secondary to infection of the pleurce from inflam- 
nialori/ changes beloiv the diaphragm ; thus appendicitis may lead to micro-organisms tracking 
up behind the ascending colon to reach the diaphragm, there perhaps producing a small 
subdiaphragmatic abscess, or a local inflammation which, stopping short of pus formation, 
ultimately subsides. The bacteria in contact witli the lower surface of the diaphragm can 
pass through the latter arid infect the pleura without there being any actual perforation of 
the dia|)hragm ; it is noteworthy that passage of micro-organisms in the reverse direction 
is so rare as almost to be negligible ; acute peritonitis often [jroduces acute pleurisy, but 
the latter, or even empyema, seldom produces peritonitis. Any inflammatory mischief 
below the diaphragm may lead to dry pleurisy, jjleuritic effusion, or empyema. One need 
not enumerate all such causes, but they should be borne in mind as possibilities. There 
may have been acute general peritonitis, or a more local inllaniiiiatinn of the peritoneum 
tracking in the manner already described in connection with ap])<ndicitis. This is possible 
when there is leaking from a gastric or duodenal ulcer ; local infection from the gall-bladder ; 
pyosalpinx : ])elvic peritonitis due to whatever cause : perinephric inflammation secondary 
to renal calculus or injury, acute ascending nephritis, tuberculosis of the kidney ; hepatic 
abscess or otlur inllanunatory changes in or about the liver, such as infective cholangitis, 
suppurative pylephlcljitis, or the softening and breaking down of new growth, gumma, or 
hydatid cyst. When the possibility of a pleuritic effusion being secondary to an abdominal 
lesion of some kind is borne in mind, the diagnosis of the case is generally indicated, at 
least approximately, by the preceding history and symptoms. It the fluid obtained smells 
as though it were infected with Bacillus coli communis, this would be an additional argument 
in favour of some subdiaiihragmatic cause. 

InfarrliDii of the lung, wliitlur thrombotic or embolic, is apt to cause dry pleurisy : but 
if the infarct has been extensive, or is due to embolism from some septic source such as a 
lateral sinus or jugular vein thrombosis in connection with otitis media, or other similar 
lesions causing venous clotting, the inflammation of the pleura tends to go further and 
produce an effusion which, at first serous, may later become pundent. The diagnosis is 
sometimes oijvious ; but when after an operation, perhaps for excision of an inflamed 
appendix, the patient a few days later develojis pleurisy with effusion, it may not occur to 
one that a possible explanation of the trouble is that more than one systemic vein in the 
region of the right iliac fossa has become inflamed and thrombosed, and that portions of 
the clot have been detached and carried to the lung, where multiple infected emboli ha^•e 
led to pleurisy and serous effusion, without going so far as to produce either abscess in the 
lungs or empyen>a. .Should h;pmoptysis occur in such cases, as it sometinics does, phthisis 
may be feared ; but it will be excluded l)y tlic al)scncc of tubercle bacilli on repeated 
examination of the sputum. 

Occasionally the fluid obtained on needling the chest is distinctly chi/lous, in which 
case the first suspicion to be aroused is that there has been some interference with the 
thoracic duct, either by injuri/ or by an intrathoracic neiL' groictli. Sometimes, howevei-. 
this rare symptom is flue to remoter causes, such as chronic nephritis or Icuka'uiia, just ;i-- 
tliese may occasionally i)ro(luce chylous ascites (see p. 50) ; in a few instances a chylous 
effusion into tlie chest has cUarcd up alter tapping, and no ascertainable cause for it found. 

Multiple serositis or polyorrhomenitis is a term used to express any condition in 
which there is recurrent inllammation and serous effusion into more than one serous mem- 
brane. It generally affects the ijeritoneum. pericardium, and both pleiu'a? either sinudtan- 
eously or successively. It is not a disease in itself, so that the differential diagnosis of the 
cause of the combined effusions has to be made upon the same lines as that described for 



CHEYXE-STOKES RESPIRATION 107 

each separately. There are cases in which, even when the patient dies, the precise nature 
of the multiple serous inflammations and effusions is obscure ; it is very possible that the 
original microbial cause has disappeared, leaving behind it so much fibrotic thickening of 
the membranes that even the normal secretions arc unable to drain away as fast as they 
should. The result is that recurrent tapping at comparatively short intervals becomes 
necessary, and the patient ultimately dies of exhaustion, nothing being found post mortem 
except fibrous thickening of the peritoneum, pericardium, and pleurfc. with more or less 
extensive perihepatitis, perisplenitis, adherent pericardiimi, and chronic mediastinitis. 
The general opinion is that the primary cause in these cases has been either acute rheuma- 
tism or tuberculosis. Sometimes secondary malignant disease affects more than one of 
the serous membranes at the same time, and produces a clinical picture which at first 
simulates chronic simple polyorrhomenitis : there are generally symptoms due to the 
primary growth : but occasionally, especially in connection with diffuse carcinoma of 
the stomach — " indiarubber-bottle ' stomach — the primary growth causes no symptoms, 
and the nature of the multiple serous effusions may be obscure unless particles of new 
growth can be detected in the ccntrifugalized deposit, or secondary masses can be 
found in the liver or lymphatic glands. The left supraclavicular glands should be 
examined carefully (Fi^. 17, p. 49). Sometimes the diagnosis is not arrived at until a 
post-mortem examination is made. 

Bcsirlcs chronic tuberculous, rheumatic, and malignant polyorrhomenitis, a similar 
condition may be <luc to Bright's disease or any of the severe ana-mias ; the differential 
diagnosis of the serous effusions to which these may give rise has been discussed above. 
Careful examination of the blood and urine, together with estimation of the blood-pressure, 
examination of the optic discs, and routine physical examination of the various body 
systems, are essential before the correct diagnosis can be arrived at. Herbert French. 

CHEST, VARICOSE VEINS ON.— (See Veins, Varicosk Tuoracic, p. 7.-,0.) 

CHEYNE-STOKES RESPIRATION, or periodic breathing, consists in the occurrence 

of a siiiis (jf ins|iiraliiiiis. bigiimiiig with a hardly perceptible movement increasing to a 
inaxlinuiu. and tlicu ilccliniiig in force and length until tliey cease in a period of iipncca of 
some seconds' duration, during wliich the patient may a])pear to be dead, but at tlie end of 
which a low inspiration, followed by one more decided, anil then others of Increasing depth, 
mark the begimiing of a new ascending series of inspirations, which in their turn, when 
the maxinuuri has been reached, become progressively smaller again, to end in another 



__^iifc4^- 



period of aprioa : :in(l so on willi more or less periodicity (A'/i'. Hi). Tin- ilnralicjii of each 
I)c-rio(l Niirics from li;df a iiiiimic In two miuulcs or c\cn more, 'i'here is a peculiar variety 
of periodic breathing in which, instead of a waxing and waning se((uciu'e. only I wo or perhaps 
three rapid deep breaths arc Tnadc at a time, with long periods of apiiiia l)el\veen them — 
a variety of periodic breathing which is sometimes spoken of as Hiofs. 

Periodic breathing may occur during sleep in the very young and in the very old wilhoid 
tlu're being an\ aclnal disease. In other persons Cheyne-StoUes breathing is generally a 
late phi^norni n<iri, lia\ irig been preceded by oilier symptoms. ))articularly urainic or cardiac ; 
in a few eases ol |>l■ogr(■^si\ <■ solleiiing in the medulla oblongata secondary lo arterial 
degeneration. ( lieyne-Slokes respiralion ma\- li<' the salient symptom in the ease, liroadly 
speaking, one may elassily llie chief causes of pirioilic brcalhing as follows : 

1. Arterial, especially with Degenerative Changes in the Medulla Oblongata: — 

Ai'lirin-sclcidsis. with iir williniil <;raniilar kiiincy. 
SrniN' ill ;;(M(i:itiiiri. 



108 CHEYNE-STOKES RESPIRATION 

2. Uraemic, in cases of : — 
Acute ne[)liritis I Tuberculous kidney I Cystic kidneys 

Clironic ncpliritis Ascendinj; nepliritis, acute or Carcinoma oif the kidney 

Calculous <lise;ise ol' the kidney | chronic | Sarcoma of the kidney. 



3. Chronic Heart Failure : — 

Secondary to valvular lieart disease 
Secondary to myocardial degeneration, especi- 
ally fatty or fibroid heart 



Secondary to cluduic obstruction in the lungs, 
especially from emphysema and bronchitis, 
or I'lbroid luni> 

Associated with very high systemic blood- 
pressure. 



4. Narcotic Poisoning, especially from 

Morjihia ' Chloral ! Veronal 

Opium Hulyl chloral hydrate j Sidi)honal 

5. Macroscopic Lesions of the Brain or its Coverings : — 



Meningitis, tuberculous, su]ipurati\ e, ])osterior 

basal, cerebrospinal 
Ilydrocejihalus 
Tumour of the brain, especially of the jjons 

or medulla 



Ha?morrhaf>e 

Softening of the lirain secondary to : 
Chronic arterial degeneration 
Syphilis Caisson disease 

Embolism General paralysis 



6. Acute Specific Fevers, such as : — 

Pneumonia I Diphtheria ] Alalaria 

Cholera j Typhoid fever j Infective endocarditis 

The diflerential diagnosis of these various conditions will be indicated by symptoms 
and signs other than the Cheyne-Stokes rcs|)iration. for the latter will have occurred late 
in the great majority of the cases. The urine will be examined, the blood-pressure measured, 
the physical signs of the heart noted, the retina examined lor retinitis, optic neuritis, or for 
choroidal tubercles, and careful in(|uiries will be made into the history. Where narcotic 
jioisoning may be suspected, the gastric contents may be recovered and analyzed, bottles 
foimd imder suspicious cirevmistances may be examined in the same way, or evidence of 
iiypodermic injections sought for on the patient's body or limbs. When Cheyne-Stokes 
respiration occurs as the main symptom in the case, the great probability is that there are 
degenerative changes in the medulla oblongata, nearly always secondary to arterial degener- 
ation, either senile, syphilitic, or sclerotic. When there have been obvious symptoms of 
some other kind before Cheyne-Stokes respiration develops, the latter is far more important 
from the prognostic than from the diagnostic standpoint. It is a sign of evil omen, though 
in a few cases it has persisted for inaiiy months before the end came, and in a few it has 
<lisappcared entirely for the time being, even after it had been well marked for days or weeks. 

Herbert French. 

CHILLS. (.See Ricohs, p 594.) 

CHORDEE. — A condition in which, during erection, the penis, instead of remaining 
straight, becomes curved like a banana, either downwards or to one side. It is nearly 
always due to gonorrhcca, though in rare cases it has residted from injury without gonor- 
rhoea. The differential diagnosis will depend upon the history and the existence or other- 
wise of a urethral discharge containing gonococei. The condition itself is probably due to 
inflammatory effusion into one corpus cavernosum, or the corpus spongiosum, as the case 
may be ; or, in the absence of inflanuiiatioii, to blood extravasation from a burst vessel. 
Fracture of the penis has occurred during resisted coitus, the diagnosis dejiending on the 
history and the break that is palpable in the penis during erection. Herbert Freiieli. 

CHYLURIA. — The passage of milky-looking urine, due to the admixture with it of 
cmulsilicd fat, is known as chyluria. It is not likely to be mistaken for phosphatmia. 
even when the latter, especially after the largest meal of the day, causes the urine to be 
almost like thin milk from the spontaneous deposition of the excess of phos])hates whilst 
the urine is still in the bladder. The opacity in the latter case disappears on the addition 
of a drop or two of acetic acid, whilst the fat droi)lcts of chyluria do not clear up with acids, 
are obvious under the microscope, and may bi' lironght out still more clearly by the use 
of special fat stains, such as osniic acid, sudan III. or salfrauin. ^Vs a ride the urine coagu- 
lates on standing, and subsei|ucntly liciuefies again, when it throws up a fatty sciun and 



t'LAW-HAXD 



109 



deposits ii seflimcnt. Tlic fat is most plentiful after meals whicli contain fat: tlie degree 
of chyhiria consequently varies considerably in the same patient, and may sometimes be 
almost absent. 

The commonest cause for the symptom is infection by Filariu sanguinis liomiiiis in 
the tropics, adults being affected more often than children, and females more often than 
males. There may or may not be elepltnntinsi.i at the same time : the diagnosis may be 
suggested by eosinophilia and confirmed bv the discovery of tlie embrvos in the blood 
(Plate XXVIII, Fig. F, p. 614). 

C'hyluria may also occur, however, in those who have never been abroad, and it is 
sometimes associated in some way that is not yet fully understood with sub-acute nephritis ; 
there may be chylous ascites (p. .50) at the same time. Tlie diagnosis depends upon the 
history, the general crdema, the anemia, cardiac hy])ertrophy, and upon the discovery of 
an abundance of albumin with renal epithelial cells and tube-casts in the centrifugalizcd 
urinary deposit, as well as fat droplets in the su])ernatant fluid. 

Sometimes chyhiria develops (juite ajiart from any 
renal lesion, either spontaneously or as the result of 
abdominal injury ; and it has generally been found in 
these rare cases that there has been either rupture of 
the receptaculum chyli, or else a blockage in the 
thoracic duct. The latter sometimes results in cases of 
malignant disease, especially carcinoma of some intra- 
abdominal organ with secondary deposits in the glands 
in the posterior mediastinum. The development of 
chyhiria in such cases would be a late symptom, and 
the diagnosis would probably have been made already- 
on account of other symptoms, especially the discovery 
of a primary tumour. It is important not to forget 
rectal and vaginal examination, lest the growth should 
be pelvic. IlcrhnI Frnirh. 

CLAW-FOOT (Pied-en-griffe) {Fig. -14). is mueli 
less coiniiHiri lli.iii t i, \\\ -ii am>. but it may arisi' IVoin 
similar <auses. The iiihinal i)(i|)liteal nerve, which 
supplies the intcrossei and hiinbricals of I he fool Ihroiiali 
its externa! plantar branch, is homologous to the ulnar 
nerve in the upper extremity. Its buried ((iimsc in [\iv 
leg does not, however, expose it to the same ehauccs of 
injury as the more superlicial ulnar nerve, and eoiise- 
MMintly claw-foot is not often the result of trauma. 
Disease or injury of the first and second sacral segments 
of spinal roots may produce the characteristic deformity 
of the toes, in which case there would probably be dis- 
turbances of sensibility in tlie corresponding cutaneous 
areas. In aT-ute poliomyelitis affc<'tiiig those segments, 
history of onset, as in llie case of claw-liaii.l of siniif 




/•'W. n.--Clau-lV,ot. 



I lie dia,! 
iriyiii. 



iiosis (I 



■|,.n,N 
n,i„h,n 



on llic 
lUa-.aril. 



CLAW-HAND (Main-en-grirrc) is IIk- n-.uw used to describe a hand el.ara.cteri/cd 
l>y a claw-like position of the lingers {Fig. I.-,), 'i'he lingers are extended at the mclacarpo- 
]plialaTigcal joints and Hexed at both iMici-phalaiigeal joints. This iiosilion is the result 
lof the over-:ulion of the extensor coinnuuns digitorum and llexores digitorum when un- 
jopposed by the normal antagonism of the inlerossei and luiMbrieales. It is not symptomatic 
j'>r any particular <lisease. but results from any nuirbid condition which produces atrojiliic 
jjiaralysis of the intrinsic hand muscles so long as the long extensors of the lingers remain 
Snfaet. I'rogressiir mimciilar alrojiliii, ulnar jiarali/sis, sf/ringonii/cliu, (rrvical parhi/nirningilis 
(iculc jiolioini/rlilis. pemncal alroiili//. and supeinumerarij ribs arc among the conditions 
winch may give rise to claw-hand to a lesser or greater degree. In any particular case 
he diagnosis of the underlying eondilion depends on the nsull of fiirtiicr investigation. 

In progressive muscular alrajih!/. uiisling ,,[ llii' iiil ririsic ImikI nuisclcs is often an early 



110 CLAW-HAND 

symptom (p. 61), and a claw-hand may develop before the long extensor muscles of the 
fingers have become involved in the disease. All four fingers are usually affected to an 
a]>proximately equal extent, and there is often marked wasting of the thenar and hypothenar 
eminences. When the abductor pollicis is also involved, the thumb tends to come into 
line with the fingers and gives an appearance to the hand resembling that of the ape (ape's 
hantl). The flexors of the wrist often become involved before the extensors, with the 
result that the wrist is hyperextended, and a ' |)reaclier".s hand ' results. The absence 
of pain and of all sensory disturbance, the gradual onset, and the general exaggeration 
of the deep reflexes, serve to distinguish this condition from some of the other causes of 
claw-liand. 

In iihifir paralj/sis the claw-position i.s more marked in the ring and little fingers than 
in the middle and first fingers, owing to the fact that the two outer lumbricals are supplied 
by the median nerve. The adductor pollicis is the only thenar muscle to .suffer, but the 
hypothenar eminence is wasted. If the injury to the nerve is above the point where it 
gives off the branch to the flexor carpi ulnaris, the latter muscle will also be paralyzed, 
and flexion of the wrist will be carried out with a leaning towards the radial side. In ulnar 
paralysis the palsy is limited to the muscles supplied by the ulnar nerve, and there is 
usually some sensory loss in the area of skin innervated by the latter. 

The claw-hand of si/ringo- 
myelia (Fig. 45) resembles that of 
]3rogressive muscular atrophy in 
general appearance, and may show 
the modifications to which the 
term " ape's hand ' and " preacher's 
hand ' have been applied. The 
muscular atrophy is not limited 
to the distribution of a single 
nerve, but involves the muscula- 
ture innervated by the eighth 
cervical and first dorsal spinal 
segments, — the segments, in fact, 
in which the gliosis frequently 
Fi,,. ij -tiriiigomyeik- ci.iw i,;ir.,i. begins. The diagnosis depends on 

the presence of dissociative anaes- 
thesia, trophic and vasomotor disturbances such as whitlows, glossy skin (peau lisse), 
main succulente, and is often corroborated by the occurrence of oculo-pupillary pheno- 
mena, nystagmus, scoliosis, and evidence of spastic paralysis in the leg of the same side. 
Cervicnl pnrlii/inrningitis only leads to a claw-hand when it interferes with the function 
of the eighth cervical and first dorsal anterior roots, and leaves uninjured the sixth and 
seventh cervical roots. The condition is generally bilateral with some asymmetry, and it 
is usually associated with pain and ill-defined disturbances of sensibility in the two arms. 
An acute poliomyelitis affecting the eighth cervical and first dorsal segments, and 
lea\ing intact the sixth and seventh cervical segments, is uncommon. The history of 
acute onset, with constitutional symptoms such as headache, fever, vomiting, and convul- 
sions, affords a clue to the diagnosis. The absence of sensory loss, and the possible presence 
of atrojihic palsies in other parts of the body, form additional data in these cases. 

In peroneal atrophy the diagnosis depends on the symmetry of the afi-ection and the 
preceding or concomitant atrophy of the leg muscles, generally beginning in those supplied 
by the peroneal nerve (see Figs. 20 and 21, p. 60). 

Supernumerarji eervieal ribs may lead to the ijroduction of a claw-hand when they 
cause neuritic changes in the trunk formed by the eighth cervical and first dorsal eon- 
trilnitions to the brachial plexus. The muscular atrophy is preceded by pain in the 
arm and neck, and sometimes by vasomotor changes and diminution "of the radial 
pulse. Analgesia in the distribution of the eighth cervical and first dorsal-root areas 
may also be detected, but the diagnosis mav depend mainly on the skia^raphic discovery 
of the rudimentary ribs (,,. 443). ' E.°Far,p,l,ar Buzzard. 

CLONUS, ANKLE.— (See Ankle-clonus, j). 39.) 




CLUB-FOOT 



111 



CLUBBED FINGERS, or bulbous cularuemcnt of the soft parts of tlic terminal 
])lialani;es, with o\ei-cui\in<;- of the nails both transversely and longitudinally, are seen 
eharaeteristieally in mor))us ca^ruleus. and also in association with fibroid lung. They 
are distinguished readily from enlargement (hie to bony changes, such as those of acromegaly 
and pulmonary osteoarthropathy. 

Minor degrees may occur with almost any disease that leads to persistent congestion 
of terminal ]jarts, such as mitral stenosis, mitral regurgitation, emphysema, chronic 
bronchitis, pleurisy with effusion, empyema, chronic phthisis, some form.s of aortic or 
subclavian aneurysm, asthma, pericarditis, adherent pericardium, mediastinitis, or 
mediastinal neoplasm. In such cases, however, the clubbing has to be looked for — it does 
not thrust itself (ipon one"s notice ; it may also pass away again -when the cause is removed, 
for instance, when an empyema is 
cured by operation. 

Obvious and extreme finger-club- 
bing has only two main cavises — 
congenital heart disease with cyanosis 
(Fig. 46). especially pulmonary stenosis 
with or without a perforated interven- 
tricular septum : and fibroid lung, 
especially if associated with bronchi- 
ectasis. The distinction between these 
two will generally be obvious. The 
former dates from infancy and is 
associated with extreme cyanosis and 
a loud pulmonary systolic bruit an<l 
thrill ; the latter develoi>s later in 
life, is seldom associated with such 
extreme cyanosis cxcejjt when the 
patient is in extremis, and is accom- 
panied l)y displacement of the heart 
and other signs of fibrosis of the lung. 

Difficulty may arise in those rarer 
cases of congenital h;'art disease in " .xtrcinc rv:iii"M>. 

which there is no bruit — for instance 

when the heart gives off a single large vessel, tlie place of the pulmonary arteries being 
taken by intercostal vessels — but even here the fact that the lividity is out of jHoportion 
to the dyspncra, and the history that the cyanosis and the finger-clubbing date from 
soon after birth, afford immediate clues to the diagnosis. Congenital heart disease with- 
out cyanosis— patent duetvis arteriosus, for instance — does not give rise to clubbed fingers. 
In lung eases the diagnosis is either obvious from the i)hysical signs : or else, if the 
abnormal physical signs are so slight as by themselves to suggest little more than bron- 
chitis, the existence of marked clubbing of the lingers is iini)orlant evidence that the 
lung trouble is more extensive than this, and that there is really nuich fibrosis, and prob- 
ably bronchiectasis, too deep-seated to permit of the usual physical signs being detected 
at the surface of the chest. \ moderate degree of clulibing of the fingers is sonielimcs 
observed in cases of cirrhosis of the liver. i)arl icularly in that l>pc which begins as splenic 
anicmia — Hanli's disease (see' p. .'IT). This su:;g<>sls thai Hie changes in the linger lips 
have a chemical as well as a mccliaiiicMJ factor in llicir causation. Iliihcil l-'irnch. 




CLUB-FOOT, or TALIPES. Any dclbrmily of the fool not limited to the toes 
(■(iTinnoiils yocs uiiilcr Ihi- narnc of club-foot, or talipes. .The diagnosis of the differenl 
Iciiiiis of lali|Hs is cxliciiiily dillrciilt. owini.' lo (lie tninibcr <if causes ;uul the coinplicaled 
nalin-e of the ilcformil iis. 11 ina\ In- well. Ilicn lorr. In il.line liriclly llic chief variclics 
of simple dcl'ormily. 

1. Talipes Equinus. In lliis coiKlilinn Ihc line pari of llir fool caiinol lie raised 
lo the normal dcgrei'. Any lieallliv adiill is able, willi I lie knee sliaiiilil, lo ilorsill.'X Hie 
aiikli' lo such an extciil Ihal llii- ball of llie -iral loc is I wo or Ihrce iiicliis liiglicr lliaii Ihe 
proriiiiuiice of the heel. 'I'lic (l(i;nr of dorsillexion is e\cn "Tialcr in iiifaiils, bill uilh 



112 CLUB-FOOT 

advancing years the movement beeomes limited, so that old people may hardly be able 
to dorsiflex the foot beyond the right angle. 

2. Talipes Calcaneus. — In this condition the heel is depressed and tlie fore part of 
the foot elevated. Kxtension of the ankle is limited, so that the fore part of the foot may 
not touch the ground in walking. 

:!. Talipes Valgus. — The foot is everted and abducted at the ankle-joint, so that the 
inner malleolus is too prominent. 

4. Talipes Varus. — The foot is inverted and adducted at the ankle-joint, so that the 
outer malleolus is too ])rominent. In this condition, however, there is more serious 
deforniity at the medio-tarsul joint, at which the fore part of the foot is adducted and 
inverted. 

5. Talipes Cavus. — The arch of the foot is too high or hollow. This may be due to 
depression of the fore part of the foot, of the heel, or of both. 

Club-feet may be divided into (I) The Congenital, (II) The Acquired. 

I. CONGENITAL TALIPES. 

Congenital talipes is usually quite easy to diagnose, because of the history of the 
liresence and the nature of the deformity at birth. There are two chief varieties of it : 

(1) Equino-varus ; (2) Calcaneo-valgus. 

Sometimes the history is lacking or misleading, and the shape of the feet has been 
so altered by treatment or neglect that it is very dilficult to distinguish the condition from 
paralytic talipes, especially that due to paralysis of the lower neuron. In making the 
distinction it is important to remember that the shortening is usually very much less in 
congenital cases, and that wasting of the muscles, apart from tight splinting, is also much 
less. Trophic idcers, and cold and blue feet, which are common in cases of paralysis, do 
not occur in congenital talipes. Moreover, the toes are not hyper-extended at the meta- 
tarso-phalangeal joints, a condition commonly present in jiaralytic talipes. The reaction 
of degeneration is not present in congenital cases, thus distinguishing it from talipes due 
to comparatively recent paralysis of the lower neiu'on. The reflexes are not exaggerated, 
thus distinguishing it from talipes due to paralysis of the upper neuron. In congenital 
equino-\arus the small conical heel is not only raised but also turned inwards in a character- 
istic way, and it is generally separated from the inner aspect of the foot by a deep furrow. 
There is also a curious flattening on the outer side of the foot, just in front of the external 
malleolus, where the skin is dimpled and loose. There is also a furrow on the inner side 
of the foot opposite the medio-tarsal joint. The varus is always worse than the ecpiinus, 
whereas in paralytic cases the equinus is usually worse than the varus. With care the 
overstretched weak muscles can be shown to be capable of voluntary contraction. 

II. ACQUIRED TALIPES. 

This condition may be sid)divided as follows : (1) The paralytic, due to : (a) Disease 
of the upper neuron ; (b) Disease of the lower neuron ; (c) Primary muscular disease ; 

(2) Postural, e.g., talipes valgus ; (3) Due to fibrosis of muscle, with retraction : (-1) Due 
to bone disease : (5) Due to joint disease ; (6) Due to contracting scars ; (7) Due to 
hysteria. 

1. The Paralytic. — (a) In talipes due to destruction of the iqrper neuron the reflexes 
are exaggerated and the plantar reflex is extensor ; whereas in talipes due to disease of 
the lower neuron the reflexes are unchanged, diminished, or lost. Reaction of degeneration 
may be present with lesions of the lower neuron, and absent with lesions of the upper. 
Coldness and blueness of the feet are only common in lesions of the lower neuron, and the 
same is true of trophic ulcers. The shortening and wasting are generally nnich greater 
in lesions of the lower neuron, and the distribution of the paralysis is much more irregular 
than in those of the upper. When the disease of the upper neuron is in the brain, it is 
usual for the arm as well as the leg to be paralyzed {infantile hemiplegia), or both feet may 
be involved synmietrically {congenital spastic paraplegia). Occasionally there may be a 
cerebral monoplegia. In any case the deformity due to disease of the upper neuron is 
almost characteristic, and is mostly ecjuinus, usually with a little valgus, but occasionally 
with slight varus ; whereas when the lower neuron is affected the deformity is nearly 



CLUB-FOOT 113 

always equino-varus or talipes vali;us. In distinguishing various destructive lesions of 
the upper neuron, the history and tlie natvire of the deformity may help. In hemiplegia or 
monoplegia there may he a Iiistory of difficult labour, with delivery by forceps, indicating 
injury to the cerebral cortex, or meningeal haemorrhage with secondary fibrosis of the 
motor area. Tlie deformity may not be obvious for a year or more after birth, and it is 
usually noticed first when the child begins to walk. In other cases it may be due to 
thmnibosis of the cerebral veins following measles or influenza, or to rupture of some of the 
cortical veins during whooping-cough or violent fits of passion. Congenital spastic para- 
plegia is distinguished by its symmetry, and by the amount of spasm as shown by the 
unexpected degree of flexion of the ankles that can be produced by firmly pressing upwards 
the fore-parts of the feet. Moreover, there is usually some mental incapacity, and often 
the history of nervous disease in the family. When the lesion is in the spinal cord, there 
may be a history of spinal injury or evidence of spinal caries, or of growth causing a spastic 
paraplegia. In amyotrophic lateral sclerosis there are signs of paralysis and wasting of 
the upper limbs. Friedreich's disease, or hereditar// ataxi) is an occasional cause of talipes 
equinus or equino-varus. It can be recognized by the inco-onlination, the nystagnius, 
the slurring of speech, the age of onset, which is usually about six to nine years, the absence 
of knee-jerk, and the Ivillux erectus. 

(h). Lesions of the loicer nearon may be in the cord (infantile ))aralysis), or in the eauda 
equina (spina bifida), in the lumbo-.sacral cord or sacral plexus (e.g., carcinoma of the 
rectum), or in the periplieral nerves (peripheral neuritis injured sciatic nerve, or Tooth's 
neuro-muscular paralysis). Infantile paralysis results from acute anterior poliomyelitis 
and is distinguished by its irregular distribution, reaction of degeneration, and its vaso- 
motor and trophic lesions. It is frequently possible to show that the patient is unable to 
use certain nniscle.s or groups of muscles, especially the anterior tibial and peroneal group. 
II is unusual for the paralysis to be limited to the leg ; the thigh is often affected to some 
extent, and often tiie oi)posite leg. It is important to examine for spina bifida ; talipes 
due to this is not ueecssarily symmetrical ; one foot may be involved more than another, 
and the deformity is often progressive. I have seen several cases of talipes calcaneo-valgus 
associated with it. and also pure cavus, and one very bad ease of e(juino-varus of one foot. 
and equino-valgus of the other. The foot may drop in peripheral iienrilis due to diphtheria, 
lead poisoning, or alcoholism. In each of these conditions there is other evidence of the 
disease. In many cases of growth in the pelvis the foot may drop owing to invasion of the 
sacral plexus by the growth, which may be either sarcoma of the pelvis or carcinoma of 
the rectum. Wounds of the thigh, or the jiressure of tight splints in the treatment of 
fracture, or the forcible extension of a contracted knee, may lead to paralysis of the sciati<' 
nerve, es|)ecially of its external poiiliteal branch. This may lead to talipes e(iuino-varus. 
A similar deformity may follow injury of the lumbar s])ine with secondary hienuito-rhachis, 
or growth anywhere in the course of the sciatic nerve. I ha\c known it follow the use of a 
Ilodgen extension apparatus. Tooth's nciiro-miisniUtr ii(ir(d//sis (Figs. 20 and 21, p. <>(!) 
causes paresis of the anterior tibial and peroneal nuiseles, with talipes c<|uino-varus and 
marked cavus, and deformity of the toes. It may be distinguished from infantile paralysis 
Ijy the synunctrical affection of both feet, by the wasting of the thenar eminences, and the 
hi.story of similar deformity in the family, and from the primary nmscular dystrophies 
by the occurrence of reaction of degeneration. 

(r). /'riniarif Miisriilar Disease. - In primary muscular paralysis (see .VruoiMiv, Mrs- 
(11. All, p. ,")!») talipes may be developed late in the disease ; but as a rule the patients do 
iiol li\c long enough for the deroriiiily to become a striking feature. The family history 
assists the diagnosis, and in the pseudo-hypertrophie form there is the charaeterlslie way 
in which the patient raises himself from the supine position by rolling into the prone position 
.111(1 then lifting himself on his toes and hands, and working his hands up the fronts of the 
lliiyhs. 

2. Postural. — .\c(|uircd talifies \algus may be due either to jjosture or to paralysis 
ol I he tibiales muscles. When a patient attempts to adduet and invert the fore-part of 
Hie fool, the tendons of these muscles can be seen to stand out when they are not jjaraly/.ed. 
The foot may be forced into a cramped i)osition by tight boots, and a form of talipes 
cavus may thus develop, with marked deformity of the toes, which are hyper-cxtended at 
mctatarso-phalangeal joints and flexed at the others. This condition nuist not be 

I) 8 



114 CLUI3-FOOT 

founded with a similar one due to paralysis of the small muscles of the foot, especially 
the intcrossci and lumhricales. 

3. Fibrosis and Contracture of the Muscles of the Calf. — Very rarely the calf muscles 
may contract as a result of an isehainia analogous to that occurring in the fore-arm, and 
leading to contracture of the wrist and fingers (Volkmann's contracture. Eig. 58, p. 141). 
The same condition may develop as a result of cellulitis of the calf muscles, often 
associated with comiioimd fracture of the leg. or with acute necrosis of the tibia. In all 
these conditions it is iinjiortant to prevent the development of talipes equinus. 

4. Bone Disease. — Injury or inflammation of the tibia near the epiphysial lines in 
youtli may lead either to arrest or over-growth of the affected bone. This is not uncommonly 
a cause of tali])es, which can be recognized if care be taken to make comparative measure- 
ments and ,i-ray examinations of the bones. 

5. Joint Disease. — In fractures into the ankle joint, such as Pott's and Dupuytren's 
fractures, a very bad form of talipes equino-valgus may form unless care be taken to 
correct the deformity and to keep the ankle moving. Talipes equinus may arise as a result 
of the maltreatment of sprains or arthritis of the ankle, either septic or tuberculous, unless 
care be taken to keep the joint dorsi-flexed during treatment. 

6. Contracting Scars. — Occasionally tali])es equinus follows severe burns or lacera- 
tions of tlie skin of the leg or foot. The diagnosis is usually obvious from the scars. 
There may be some wasting of the muscles from want of growth of the limb from disuse. 

7. Hysteria. — Hysterical club-foot may be susjjected from the associated symptoms 
and confirmed by the absence of any change in the electrical reactions, by the variation 
of the deformity, and the disproportionate amount of spasm, whicli passes off during slcej) 
and inider an anaesthetic. 

Finally, it is to be remembered that if a normal muscle is left in one position over a 
long period with its points of origin and insertion unduly approximated, it may presently 
be found to be impossible to lengthen it out ))roperly again ; it is in this way that contrac- 
tures of muscles are apt to occur during the course of long febrile illnes.ses — enterica for 
instance — when the patient may remain curled up in bed for weeks. If the limbs are 
jiassively extended and flexed each day. no contracture results, but it sometimes happens 
that the neglect of this precaution is followed by persistent contracture of what had hitherto 
been normal muscles, and one of the likely results of this is club-foot. 1{. p. Hozclaiiils. 

COITUS, PAINFUL.— (See Dysparkuxia, j). 193.) 

COLIC. — This is a word often used very loosely for any severe abdominal pain, 
especially of a kind which tends to wax and wane in intensity. Such pain may be associ- 
ated with disease in almost any one of the abdominal viscera, and the word colic is applied 
(|uite commonly to the pain caused by the passage of a calculus down the bile-duct (biliary 
<olic) or the ureter (renal colic). The name ' mucous colic ' is also used by some writers 
for the disease usually known as muco-membranous colitis. It is better, however, to 
restrict tlie term colic, used without a qualifying adjective, to pain caused by contraction 
of the intestine, of a cramp-like nature, caused by local irritation or by general poisoning, 
in the absence of any organic disease of the bowel. Diagnosis therefore mainly consists 
(1) /;( c.vcluding such organic affections ; and (2) In ascertaining, so far as possible, the cause 
of the local spasm. 

In order to exclude organic disease a careful examination of the whole abdomen 
is needed, as well as observation of the general condition of the sufferer. It must be 
remembered that in simple colic there may be vomiting, sweating, and some degree of 
collapse owing to the severity of the pain. The patient's temperature is not, however, 
usually raised ; the abdominal walls move freely on respiration : and there is little or no 
local tenderness, pressure being often a relief to the pain, so that the sufferer tends to press 
his abdomen against a pillow or other support. Though the face exliibits an expression 
of jjain, there is not the pinched, anxious facies so characteristic of grave abdominal 
troubles ; and the patient is likely to throw himself about instead of lying still as in such 
conditions as peritonitis or intestinal obstruction. The pulse is not often markedly 
affected ; it may even be unduly slow, but in nervous subjects the anxiety and pain 
may cause some rise in its frequency. 



COLIC 115 

The different affections which may give rise to abdominal pain liable to be called 
colic by patients are : Acute intestinal obstruction, intussusception, appendicitis, and 
possibly even perforative peritonitis : colitis and ulcerative diseases of the colon ; 
malignant disease of the intestine ; pancreatic disorders, acute and chronic ; gastric pain, 
especially that encountered in cases of pyloric obstruction ; intestinal neuralgia, and 
referred pains in spinal caries and in cases of pressure by tiuiiours or aneurysms : gastric 
and intestinal crises in locomotor ataxy ; chronic plumbism (p. 34) ; and renal and 
liijiary colic. 

Taking the diagnostic features separately : — ■ 

Rise of temperature above 100' F. will indicate the existence of some inflammatory 
affection, such as appendicitis. The |)ossibility of thoracic disease, such as pneumonia 
or diaphragmatic pleurisy, causing abdominal jxiin, must be borne in mind ; but such pain 
is not really colicky in character. (See Pain, Abdominal, p. -12-1..) 

Vomiting that is repeated and severe does not occur in simple colic. It suggests the 
existence of intestinal obstruction, if the temperature of the patient is normal or subnormal, 
or of some form of jieritonitis if there be fever. In the former condition a faecal odour 
may be noted in the vomit ; in general peritonitis the vomiting may be characteristic, 
large quantities of fluid being brought up with little effort : but these signs occur late in the 
course of these conditions (see Vomiting, p. 703). The colicky pains associated with gastric 
dilatation due to pyloric obstruction arc likely to end with the expulsion of a large quantity 
of foul fermenting material. The dilatation of the stomach may be ascertained by noting 
the existence of splashing in the organ when the fingers are " dipped ' sharply in the epi- 
gastric region : by eliciting an increased area of tympanitic resonance : by observing the 
peristaltic movements of the hypertrophied walls of the stomach, as seen by inspection 
of the abdomen ; by discovery in the vomit of food taken some days previously, as well 
as of organisms of fermentation (toruhc and sarcinae. Fig. 121, p. 2-tl), the vomited matter 
being generally foul and frothy ; and by examimitiou with the .c-rays after exhibition 
of a bismuth meal (Fig, 128. p. 268). 

Tenderness and rigidity of the abdominal wall are usually absent in colic. When 
conjoined, they point to affection of the ])eritoneum ; tenderness alone indicates disease 
of .some viscus, as in colitis, when it is found along the course of the colon, in intestinal 
or gastric ulceration, and so forth. 

Slight fullness of the abdomen may exist in cases of colic, but it is usually incon- 
spicuous : more often the abdominal walls are retracted. Considerable distention indicates 
some organic trouble, such as cirrhosis of the liver, intestinal obstruction, or perit<iiiilis. 
.V contracted portion of bowel may sometimes be felt. This nuist be distinguished 
from an actual tumour or inflammatory mass, and fr<mi the elongated swelling felt in 
intussusception. The si)asmodically contracted gut of colic is of small diameter, and may 
be felt to relax as the j)ain subsides and to harden again with a fresh exacerbation. 

(oiislipalion is the rule in i)aticnts suffering from colic, and if a motion is passed it 
is small and hard. The ajjpearance of diarrlnea will i)oint to some affection of the bowel, 
.such as colitis. In mucous colitis, which is associated with sc\cre i)ain. hard scybala may 
be passed*along with casts of the intestine (/''(,;;. 172. p.:{'.»8) or large shreds of mucus: these 
may- take the ioirn of rolls resembling .segments of tape-worm, but can easily be lloaled 
out if |)laee(l in water (see below). The api)earance of any blood pii' aiiuin will show that 
.something more than mere colic is present (see Hi.ooi) ri;it .Xni'M. p. 7.')). 

.MlacUs of severe abdominal pain occur in gouty and arterioselerolie subjccls. accom- 
anied by giddiness, nausea, and sonutimcs vomiting (' angina abdominalis ") : there 
may be slight jaundice^. I^xamination of the pulse will reveal increased tension and 
possibly disease of the arterial wall, and the tronble yields rapidly to nitroglycerine tablets 
and io<liil(s. 

I'ain associaird uilli -v rii(i\alilc Uiiliicv (Dicirs rc/xc.v) might be discrilicd by llie siincicr 
as colic. .Such attacks arc chaiacleri/.ed b\ sudden pain, nausea, laintncss ajiil ((illapse ; 
there may be blood in the urine (see I I.i:\i \ ri m \, p. 280). In some instances the kidney 
is cnlargcil as well as movable, owing lo dcNcloping hydronephrosis. 

InlrsliiKil iiciirrilgia may be dillicult lo distinguish from colic, as both are alike 
b]M<lional disorders without organic disease. Neuralgia is likely to occur in an ana'tnic, 
ill-nouiished person of ncurolle type; it arises without oh\ious exciting cause, anil may 



116 COLIC 

TccuT at the same time of the day with some regularity. The pain has not the cramp- 
hke character of colic, but is aching, boring, or darting. It is a very rare disorder, and 
can only be recognized by exclusion of all organic disease and of the intestinal spasm 
associated with colic. 

The gastric or intestinal crises of locomotor ataxy may be indistinguishable from colic, 
except by recognition of the other symptoms of the disease — absence of knee-jerks, ataxy, 
Argyll Robertson pupils, lightning pains and girdle-sensation. Examination of the blood 
and cerebrospinal fluid may reveal the presence of the Wassermann reaction and excess 
of lymphocytes may be found microscopically in the latter fluid. 

In children, who are specially liable to suffer from attacks of colicky pain due to 
indiscretions in diet, it is important to bear in mind the possibility of appendicitis, on the 
one hand, as a cause of abdominal pain, and on the other of Pott's disease, which may give 
rise to pain referred to the front of the abdomen. Examination of the spine in these latter 
cases may reveal the existence of rigidity and tenderness, perhaps some prominence of 
one or more vertebral spines, and examination witli the .r-rays may give positive evidence 
of caries of the bodies of the vertebrae. 

Appendicular Colic. — This term is sometimes applied to attacks of pain in the right 
iliac fossa. Their association with disease of the appendix is doubtful. Appendicitis 
may ensue subseipiently. but it is as likely that the original attacks may have been due 
to colitis (typhlitis), which afterwards spread to the appendix, as that this organ was at 
fault throughout. Unless the signs of appendicitis are present (p. 454), the condition 
cannot be recognized with certainty. In all cases of doubt as to the cause of colicky pains, 
an examination per rectum is advisable ; it may reveal the jjresence of inflammation in 
the appendicular region, or of an intussusception, in quite unsuspected cases. 

The term mucous colic is sometimes used as a synonym for nnicous colitis. The 
disease is characterized by obstinate constipation and by attacks of abdominal pain, 
during or after which shreds and rolls of mucus, or even casts of large portions of the 
bowel {Fig. 172, ]). 398). are evacuated along with scybalous masses. The casts float out 
in water and are often spoken of as " skins ' by patients who suffer from this malady. 
Microstiipieally they consist of mucus with few leucocytes or epithelial cells. 

Biliary Colic. — The passage of a calculus down the bile-ducts gives rise to severe and 
even agonizing pain in the right hypochondrium. It is of a colicky character, but it is 
apt to be more intense than that of simple colic. It may be accompanied by vomiting, 
sweating, and collapse. Shivering is frequent, and if present is suggestive of this trouble. 
The pain is likely to pass round into the right side and to the angle of the right scapula ; 
it may even be referred to the tip of the right shoulder. If the calculus lodge in the common 
bile-duct, jaundice will result. Its depth will vary with the degree of obstruction, and 
while the colic lasts it is not likely to be very intense. Palpable enlargement of the gall- 
bladder is quite exceptional in cases of gall-stones. Actual proof of the cause of the colic 
may sometimes be obtained by finding a stone in the heces, by passing them through a 
coarse sieve under a current of water. Attacks of gall-stone colic are liable to recur, and 
a history of previous illness of the same kind may aid in the diagnosis. \Vomen are rather 
more subject to gall-stones than men, and fat subjects suffer more than thin. The malady 
is most often encountered in middle life. In some instances examination with the .r-rays 
may afford confirmatory evidence of the existence of calculi in the gall-bladder ; but 
failure of such confirmation does not exclude their presence, as their substance is not very 
opatpie to these radiations. 

Pancreatic Colic, due to passage of a calculus along one of the ducts of the wland 
may occur, but can scarcely be diagnosed. It is characterized by severe, deeply 
seated pain in the epigastrium, sometimes extending to the back and loins. Exactly 
similar attacks of pain occur in chronic pancreatitis, and may be accompanied by 
shivering, or actual rigors. Intense jaundice may also be seen in this malady, and an 
enlarged gall-bladder can usually be felt. The condition can only be recognized when 
there are presmj^ther signs of pancreatic disease — wasting, pigmentation of the skin, 
and the passage of bulky, offensive stools, containing large quantities of fat. Chemical 
examination may show that much of this fat is neutral (unaltered) fat, with less than 
the usual proportion of fatty acids (p. 101). Microscopical examination may reveal 
the presence of unaltered meat-fibres in the motions. The urine may contain sugar. 



COMA 117 

and Cammidge's Tkst (p. 100) may be applied to it, though the trustworthiness of this 
reaction is not yet established. 

Renal Colic. — The distinguishing features of the passage of a cnlciilus down the ureter 
are similar to those of biliary colic, but the pain starts in one loin and radiates downwards 
to the tliigh and to the testicle in the male, to the labium majus in the female. The urine 
may contain blood, and also epithelium, from the pelvis of the kidney and from the ureter. 
Frequency of micturition is often marked, but the ((uantity of urine may be small ; it 
may even be suppressed temporarily. If the calculus become impacted in the ureter a 
swelling may subsequently appear in the loin, due to the formation of a hydronephrosis. 
The pain may cease suddenly when the stone passes into the bladder. The ,7'-rays are of 
considerable value in detecting the concretion {Fia. 192, j). 45.5). provided the bowels be 
empty so that shadows due to scybala can be avoided. 

The pain due to the presence of a calculus in the kidney can hardly be mistaken for 
colic, but occasionally the symptoms of this condition may precede an attack of renal 
colic. A history, therefore, of pain in the loin, frequency of micturition, and the appearance 
of blood in the urine, may help in the diagnosis of the latter condition. Tuberculous 
disease of the kidney, jn which the symptoms may be very similar, though apt to be accom- 
panied by more wasting and by evening pyrexia, may give rise to colicky attacks if blood- 
clots or caseous masses lodge in the ureter. Pus and tubercle bacilli may be found iu 
the urine. DictTs crises have been referred to above. 

The principal causes of Intestinal Colic are indigestible fixid. (dcoltolic excess, and lc<i<l- 
poisoning. This last should be eliminated first. It is characterized by symjjtoms described 
on p. 3-i. There will usually be a history of some occupation involving contact with lead — 
painting, glazing. ty|)e-setting. or manufacture of some compound of lead : but the possi- 
bility of poisoning by drinking-water or by beer which has stood in contact with leaden 
|)ipes nnist be remembered — the latter especially in potmen. The chief signs of alcoholism 
are given on p. 7'2(i. In cases due to indigestible food, a history of the consumption of 
Iried fish, shell-fish, jjork. raw fruit, or other suspicious matter may Ije obtained. The 
pain is more likely to move along the course of the colon than to remain fixed in the centre 
of the abdomen or at some special point, as it usually does in lead colic. In infants, colic 
may be caused by hard curds of milk, and be indicated by drawing up of the legs and 
screaming. In older children, unripe apples, plum-stones, and similar delicacies are often 
the source of the trouble, and fruit-stones may be discovered subsequently in the motions. 

ir. Cecil liosdiiijuet. 

COLOUR BLINDNESS.— (See Vision, Dei-ects of. p. 7()2.) 

COMA is a state of unnatural, heavy, deep and prolonged sleep, often accompanied 
by slou stertorous or irregular brciithing, and frequently ending in death. It may be 
due to a large number of different causes, which may be elassihcd into two main groups, 
namely : (A) Cases iu which coma is not a prominent symptom ciirly in the malady, but 
only in a late stage, when the nature of the disease has alreaily been suggested by otiier 
symptoms : .-hkI {!{) Cases iu which coma comes on carl\- and m;iy l)c tin- most prdrniiicnt 
featUH' ol the ciise. 

(hi)up A includes — 

1. Certain Severe Fevers in which coma may occur as a tcrniirial plieuomciioii : 
Tv|,hiis lever i .Measles UlacUwater lever 
Tviihoiil lexer i Scarlet lever MaliL'iiaiit malaria 

< liiilera I Ulieiuiiatie lever liifeeli\e endoearditis. 

Dysiiiteiy Yellow fever l)i|ilillieria. 

2. Acute Inflammatory Lesions of the Brain or the Cerebral Meninges : 

.\eiili- <iiee|ilialilis Taliereiiliiiis iiKiiiimitis Kpidemie cerebrospinal ineniti- 

.Suppiiialive Mieiiirii;ilis Posterior hasal meiiiiiuilis gitis, or spotted lever 

:{. Certain Less Acute Lesions of the Central Nervous System : 

Cerebral tmiinur I'ost-i |>ile|ilie slale Disseminated sclerosis 

Cerebral abscess Ceiieral paralysis ol I Ik insane Syphilis of the brain 

I'. Diseases in which General Metabolism is probably at Fault : 

Craniia t lioheniia liavnand's disease 

l)ial)etes Addiscjns disease .Mvxcrdenia 



118 COMA 

Group B includes tlie following conditions — 

1. The Results of Head Injury: 

Com|iression l>y nuniii^fal C'oiifussion ' Fracture of the base of the 

liu'morrhage lJc])rcs.sc(l fracture skull. 

2. Vascular Lesions of the Brain : 

Embolism I Thrombosis : («) arterial, {h) the superior longitudinal. 

Haemorrhage ' of a venous sinus such as 

3. The Acute Effects of Drugs, particularly : 

Alcohol i Carbon monoxide Trional 

Opium i Absinthe I Tetronal 

Jlorphia Chloral hydrate I Bromides 

Carbolic acid i Veronal Chloroform and other ana-s- 

Oxalic acid I .Sulphonal thetics. 

4. The Chronic Effects of Chemicals, cs])cciallypluiiibisui : (Saturnine encephalopathy). 
.5. The Effects of Extremes of Temperature : Heat stroke | Excessive cold. 

6. Excessive Loss of Blood from : 

Ruptured tubal gestation ILcMiateniesis Intestinal bleeding 

Post-partum ha-nicirrhagc i Duodenal bleeding | Ruptured aneurysm. 

I-henioptysis i 

7. Stokes-Adams' Disease.*^ 

8. Sudden Nervous Shock. 

9. Hysterical Trance. 

Although it is generally possible to make a broad distinction between the two groups 
cnunieiated above, it is necessary perhaps to point out that some conditions which usually 
give rise to other symptoms before they produce coma, sometimes pass mirecognized until 
coma supervenes. This applies, for example, to certain cases of diabetes mellitus, ursemia, 
suppurative meningitis, or cerebral abscess or tumour ; whilst, conversely, some conditions 
which usually exhibit coma early, may not do so imtil after there have been other sym- 
ptoms to indicate the nature of the case. It is not necessary to enter into the difierential 
diagnosis of those conditions in which other prominent symptoms have preceded coma. 

When coma is either the first or the most prominent symptom in the case, it is 
important to arrive as near the correct diagnosis as may be at the earliest possible moment, 
the case being relegated to one or other of the following four classes, which differ from one 
another radically as regards treatment : — 

1. Cases in which immediate trephining is required, e.g., for meningeal hsemorrhage. 

2. Cases in which active treatment by lavage of the stomach or by the administration 
of antidotes is required, as in opiiun or other poisoning. 

3. Cases in which active medicinal or jihysical treatment is rc(|nircd : for instance, 
diabetic coma requiring the administration of alkalies, or urtemia rc(iuiring venesection. 

•i. Cases in which absolute rest is indicated, especially in cerebral ha-morrhage. 

When investigating a case, notice first whether there is any evidence of unilateral 
paralysis : the pii]jils may be markedly unequal, one cheek may be more puffed out on 
expiration then the other, one arm or leg may fall more limply than the other ; there may 
be differences between the two knee-jerks or the two plantar reflexes ; there may be 
conjugate deviation of the eyes. If there is distinct evidence of imilateral paresis or 
paralysis, there is almost certainly a cranial or intracranial lesion — ha-morrhage, embolism, 
fracture, tumour, abscess, thrombosis or meningitis. Next, examine the head with particu- 
lar care to see if there are any signs of injury ; the presence of a scalp woimd or even of a 
fracture does not of course prove that this is the primary cause of the coma, for the (laticnt 
may have become unconscious, from a cerebral ha>morrhage for example, and in falling 
may have struck his head, in which case the injury is due to the coma, and not the coma 
to the injury. Some of the greatest difficulties in diagnosis ari,se on this account, particularly 
when the patient has previously taken sufficient alcohol for his breath to smell of it, and 
to suggest that he is drunk. Careful observation for several hours may be required before 
the diagnosis can be settled, and even then errors are sometimes unavoidable. A clear 
history is generally lacking, but if available it often assists materially in deciding the nature 
of the case. The cars and nose shoidd be examined with care to sec whether cerebrospinal 



COMA 119 

fluid or blood is coming from either, as an indication that there is a fracture at the base of 
the skull ; blood coming forward into the subconjunctival tissue may afford similar 
evidence. 

Cerebral hcEmorrhage is much more common in an elderly than in a young person, 
whilst the reverse is true of embolism. The latter may occur instantaneously, wliilst 
ha;morrhage produces coma rather more gradually ; and thrombosis, syphilitic or other- 
wise, often leads to hemiplegia so gradually that no coma occurs. The presence of albu- 
minuria with easts, with a high blood-pressure as measured instrumentally ; the history, 
in an elderly man, of a previous seizure of a similar kind with definite hemi|)k'gia, 
especially if there is also an enlarged heart with a lumpy first sound at the impulse, or 
perhaps a local systolic bruit there, with a ringing aortic second sound, would all indi- 
cate cerebral ha-morrhage, associated with defective arteries and perhaps with granular 
kidney. .Mbimiinurie retinitis should be looked for. Strong evidence in favour of 
cerebral embolinm would be afforded by a previous history of acute rheumatism aiid tlie 
existence of a ])resystolic or other bruit indicative of organic heart disease, especially if 
there are signs fp. 34) suggesting that fungating endocarditis has supervened. 

Supposing there is no evidence of a unilateral paralysis, it does not immediately 
follow that none of the above conditions are present ; one form of cerebral haemorrhage 
in particular that may cause no unilateral paralysis is pontine hcemorrhage ; this might be 
suggested at once by the very small, almost ])in-point pupils, though similar i)in-p(iint 
pupils may be due to opium poisoning. The thernionuter affords a means of (liiignosis 
between these, for opium poisoning leads to a subnormal temperature, whilst lueniorrhage 
into the pons Varolii causes the temperature to rise even to the point of hyperpyrexia. 
The diagnosis of other varieties of coma due to poisoning can seldom be arrived at accu- 
rately unless the circumstances of the ease either allow of an analysis of the gastric contents, 
or else jjoint to the |)atient having taken an over-dose of one of the drugs mentioned in 
the above list, either accidentally or with suicidal intent. The bottle may be found near 
the |)atieiit. 

Coma due to jioisouing by carbon monoride is sometimes obvious from the patient's 
bright cherry-red eoloin' ; it is impossible to convert the carboxyhiemoglobin in his blood 
into rcdueerl luemoglobin by the ordinary anunonium sulphide method : and there is 
generally direct e\ idence of the mode of |)ois()ning, such as the fact that the |)atient is 
found in a room with the windows slnit and the gas turned on, or has been subjected to 
the fumes of slow combustion from a stove, brazier, limekiln, or some other fire which 
has been burning with an insuHieient supply of oxygen. 

Saturnine enceplnilopnthi/ is very variable in its symptoms ; it may take the form of 
epileptiform convulsions ; more or less dementia ; continued coma ; acute mania ; 
in<leed. its tiniltirormity is one of its chief features. The occupation of the patient may 
point to I he diagnosis I'orthwitli, or there may be a blue line upon the gums or other signs 
of lead poisoning (p. ;M.). Not iiifre(|uenlly, however, the nature of the case gives rise 
to much perplexily before the diagnosis is ultimately made. One method of arriving at 
the latter is to collect an abundance of urine, evaporate it to dryness, and apply the tests 
for lead to the residue : or to test for lead in the lieees. The ease is apt to be mistaken for 
either cerebral liainorrhage. cerebral tumour, or getu-ral paralysis of the insane. Optic 
neuritis may he due (lireelly to phmibism. and tliis makes the dilfercntial diagnosis still 
more dillleult, unless there is clear collateral e\idenee of lead poisoning. 

Mfl.rifdema is geniTally diagnosed rniin the facics (j). 38) and general stale of the 
subcutaneous tissues, or from the results of thyroid treatment : occasionally, hdwevcr, 
one meets with a case in which the mentiil symptoms so hir outweigh the others that the 
nature of the malad\- is apt to escape attention altogether. An attiiek of coma is rarely 
the first sign, tlioiigh it may be : more oltcn there is a longish history of progressive nu'ntal 
slowness, somclimes with delusions, anil ollen associated with attacks of irascible cNcitalion 
idlernaling willi Ills of (iepression : or with bonis of mental lethargy stopping short, as 
a ri:lc. (it mcIiiiiI comim. 

(lima liiir lilliii' In liait sirii/.r iir In i\|iiisinr In r.rccssii'e cold is generali\' iiuliciilril 
by the ciillulcral e\ iiiiiiee, especially as regards the lemperature of the palienfs surrouiiil- 
iiigs, or his liasiii;; been exposed lo very sirong sun's riiys wlien at work. The chief 
dillieiilly will be to make certain that there is not any \asciilar lesion of the brain. When 



120 COMA 

there is doubt, the course of the case may indicate its nature, heat-stroke generally recover- 
ing rapidly, or ending fatally with hyperpyrexia : but sometimes, even in a fatal case, the 
diagnosis may remain in doubt imtil a post-mortem examination has been made. 

Acute encephalitis is a disease of children rather than of adults ; its general symptoms 
are those of acute meningitis ; the patient becomes unconscious more rapidly, however, 
than is usual with the latter, and yet. notwithstanding the apparent severity of the illness, 
recovery may occur, either within a few days or a week or two. The diagnosis rests upon 
the course and recovery, for in the earlier stages it will nearly always have been regarded as 
acute meningitis. The same aj)])lies to acute thrombosis of the superior longitudinal sinus. 
the diagnosis between which and acute encephalitis or meningitis is generally one of opinion 
only, unless operative measures are resorted to, or a post-mortem examination made. Optic 
neuritis,' as well as headache, vomiting, and general convulsions, may occur in all three. 

General paralysis of the insane does not as a rule give rise to coma and epileptiform 
convulsions imtil the nature of the case has been indicated already by the mental and 
physical changes — particularly the ideas of grandeur, the loss of highest cerebral control 
in one way or another, the changes in disposition, and the inability to perform the finer 
movements required for writing, dancing, playing the piano or violin, painting, and so 
forth, in which the patient may at some time previously have been an adept. Occasion- 
ally, however, notwithstanding some alterations in the mental character, the diagnosis of 
general paralysis may not have entered one's mind in a given case until a sudden syncopal 
seizure, with or without convulsions, attracts particular notice to it. It is not impossible 
that such a case may even then be mistaken for one of severe cerebral luemorrhage, and 
it may be treated as such imtil it is found that the coma, severe though it may have been, 
passes off rapidly in a way that would not have been the case had it been a haemorrhage 
of corresponding severity. The recurrence of these attacks will make the diagnosis certain, 
even if it remains in doubt for a time, and examination of the cerebrospinal fluid for 
excess of small lymphocytes or for Wassermann's serum reaction will serve to clinch the 
diagnosis in most cases. 

Severe hcemorrhage other than cerebral as a cause for coma is usually indicated at 
once by the sudden extreme blanching, not only of the patient's cheeks, but also of his 
lips and mucous membranes. The pulse-rate rises to 100, 120, or even 150. according 
to the amount of blood that has been lost : if there has been external evidence of the 
haemorrhage, the differential diagnosis will be arrived at as discussed under such headings 
as HyEmatemesis, H.i;.moptysis, MErRORRH.\GiA, etc. If the bleeding has been internal 
in a healthy person, the commonest cause is duodenal ulcer in a man, pelvic ha^matoeele 
or rujitured tubal gestation in a woman ; similar blanching in cases of typhoid fever would 
])oint to intestinal bleeding. The coma in such cases comes on suddenly, but it does not 
long remain profoimd. It is often preceded by amaurosis, and may be accompanied by 
epileptiform convulsions, so that acute uraemia may be simulated. 

When an aortic aneurysm ruptures either into a bronchus, the oesophagus, trachea, 
stomach, or bowel, the amount of blood-loss seldom leads to coma, but rather to sudden 
death ; sometimes, however, when the bleeding is into some closed space such as the 
mediastinum or retroperitoneal tissue, the blood-escape is checked to some extent, and 
acute blanching with coma precedes further bleeding and death. Rupture of an aortic 
aneurysm into the pericardium causes sudden death before the amount of blood lost has 
been sufficient to jjroduce marked blanching. 

The phenomena of Stokes-Adams' disease are described on p. 83. 

Hysterical or functional trance is an affection of young women, and it is not very 
common ; the diagnosis is arrived at by a process of exclusion, and until the case has been 
watched for some time its nature may not be obvious unless there have been other hysterical 
symptoms previously (p. 465). It is a dangerous diagnosis to make imtil every other 
possible cause for coma has been considered and satisfactorily excluded, for it is not 
difficult to jump to the conclusion that coma in a girl or young woman, really arising 
perhaps from a cerebral tumour or abscess, is due to a neurosis. It is most important 
to examine the ojjtie discs with great care, lest there should be o])tie nem-itis. the latter 
never being functional. Herbert French. 

CONJUNCTIVITIS. — (.See Kye, Acite Inflammation of, p. 231.) 



CONSTIPATION 121 

CONSTIPATION. 

I. CHRONIC CONSTIPATION. 

The indigestible residue of a meal normally reaches the descending colon in less 
than sixteen hours, and in defa-cation all the contents of the large intestine beyond the 
splenic flexure are evacuated. Some of the residue of a meal taken eight hours after 
defa-cation should be excreted at the next defalcation in individuals whose bowels are 
opened every twenty-four hours. If. however, the bowels are only opened on alternate 
mornings — a condition which is not necessarily pathological — forty hours instead of sixteen 
would elapse before some of the residue of the meal would be excreted. Constipation may 
therefore be defined as a condition in xchich none of the residne of a meal, taken eight hours 
after defwcation. is exereted uithin forli/ linnrs. Constij)ation thus defined can be recognized 
by giving three charcoal lozenges with food eight hours after defaecation ; if a blackened 
stool is not passed within the next forty hours the patient is constipated. The abnormal 
action of the bowels in constipation may manifest itself in three different ways : — 

1 . DeJiEcation may occur with insufficient frequency. A daily action of the bowels is 
merely a matter of convenience, and many people in perfect health only defsecate once in 
two cr three days. .As a rule, however, an individual may be regarded as constipated if his 
bowels are not (>i)ened at least once in forty-eight hours. 

2. 7V/r stools may be insufficient in quantity and a certain amount of fceces is retained. 
although the bowels may be opened once daily or more often. This condition (cumulative 
constipation) can be differentiated readily by the charcoal test from that in which the 
bowels are properly emptied but the fa-ces are very small in ((uantlty owing to the diet or 
to the imusually active absorptive power of the intestines. 

3. The Imicels may Ije opened daily, yet the fcrces are hard anil dry. oiving to prolonged 
retention before e.rcretion : the deficient ((uantity of water in the stools also renders them 
less bulky than normal. The stools may be similar in character when an excessive 
quantity of fluid is lost by other channels, as in diabetes. By means of the charcoal 
test it is easy to determine whether constii)ation is also present. 

After ciiiislipalioti has been diagnosed, it is necessary to determine its cause. The 
first essential is to distinguish between two great classes of constipation : that in which 
the passage through the intestiness is (lelayed whilst defa-cation is normal — Intestinal 
Constipation : and thai in which there is no delay in the arrival of f;eces in the pelvic colon, 
but their liiuil excretion is not performed adequately — I'clvi-rrclal Constipation or Dyschezia. 

.I.^DIA(;.\()SIS HKTWKKN IXTKSTIX.M, ( OXSTII'ATIOX AXI) 1)YSCIIKZL\. 

.\ rectal examination shouiii be macic in llic incirtiing. aftrr an attempt has been made 
to open the bowels without the assistance ol mcilicitie. enemala. or suppositories. If more 
than a very small i|uaiitily of fa'ces is found in the rectum, dyschezia may be diagnosed. 
If the rectum is almost or cpiite empty, tlie constipation must be due to delay in the passage 
through the intestines, except in uncommon cases of dyschezia in which there is inability 
to pass fa-ces from the pelvic colon into the rectum. The latter condition can be recognized 
on rectal examination, if the pelvic colon is felt through the front wall of the rectum to be 
lilled with solid fa'ces : the prt-scncc of fa'ces in the pelvic colon can also be jiroved by 
signioidoseopie examination made .it once, without preparation of the ])atient by washing 
out his bowils. 

.\t the same time Ihc alidnnieu shdiild be palpaUd. If s( yh.-ila are felt in any part 
of till- eiilon. iiilislinal coiistipal ion iriusi he presciil. This is. hiiwcxer. not necessarily 
till- case it r:r<(s arc tell in Ihc iliac or pil\ ic (miIhii. as the rectum ill dyschezia may be so 
full of I'li-ccs that reli'iilidU oeciiis seciniilarily in the p<i\ ic eohui ;ind rectum: such a 
eiiiidilioM would be rcengni/.ed by the rectal c-Naminatioii. 

When a palii'iit h-cK IIkiI tlicre is somclhiiig in his rectum which he eaimcil e\pel al all. 
or Ihal aller delacal imi Ihc iilicr is iiienmplcte. d>scliezia is jirobablv present. The 
aliseiicc iif this symploin dues mil c\elii(le the possibility of dyschezia as the rectum is 
often so insensitive in such cases Ihal no sensation is experienced. e\-cn when it is tilled 
tiglitly with faeces. The frcijucnt passage of very small pieces of hard fa'ces (fragmentary 
constipation), or the oei'urrciicc of psi udo-diarrlioM in which small iliiid stools, sometimes 



122 CONSTIPATION 

containing hard fragments ot feces, are passed, although the charcoal test shows the 
presence ot constipation— are both symptoms suggestive ot dyschezia. 

Some indication, which is not, however, absolutely reliable, can be obtained from 
the results of previous treatment. Patients who have found that diet and mild aperients 
readily give them relief are probably suffering from intestinal constipation. Those who 
have obtained better results with enemata, and particularly with suppositories, probably 
have dyschezia. Dyschezia is of course also present in those patients who have to dig 
out the fa-ces from the rectum with their fingers. 

Examination with the a;-rays is the only method by which the two classes of const iini- 
tion can be separated with absolute certainty, and by which the predominant conditi.m 
can be discovered in cases in which both are jjresent together. Two ounces of barium 
sulphate mixed with porridge or bread and milk are taken at breakfast, and at intervals 




Fig. 47.— Habitual Constipation. Ti 
after bismuth breakfast. No bLsnii 
beyond the first two inches of the i 
Subsequent examinations showed that 
occurred along the whole of the larje 




Fig. 4S. — Dyschezia. Twenty-four hours after bi 
nnitli breakfast. -\U the bismiitli has collected in tl 
tlilateil colon and rectum, except traces which remain 
the transveree colon. In spite of this the patient felt i 
de.-iire to deficcate. 



during the next two or three days observations are made of the shadow produced on the 
fluorescent screen. The colon should be emptied as completely as possible by aperients 
and enemata for two or three days, but no medicine should be given the day before the 
examination, on the morning of which an enema must be used if the bowels have not acted 
naturally. During the period of observation no aperients or enemata should be given, 
and the patient should be allowed to continue his usual occupation and to take his ordinary 
diet. In intestinal constipation, delay is ob.served in the passage through some part or 
all of the colon, and occasionally the small intestine : in dyschezia there is no delay in the 
intestines, but the act ot defalcation does not empty the pelvic colon and rectum com- 
pletely (Figs. 47, 48). 

B. DIAGNOSIS OF THE CAUSE OF INTESTINAL CONSTIP.VTION. 



Intestinal constipation may be due to (1) T//c motor activily of the intestines being 
(Icftcient ; or (2) The force required to carry the fceces to the pelvic colon being excessive. 
In the first group of cases aperients are generally much more effective than in 
the second ; in the latter there may be a history that purgatives are producing 
less effect than formerly, or that they now completely fail to act, but that enemata 
still give a more or less satisfactory result. The increased activity of the intestines 
in their attempt to respond to the excessive demands in the second class often leads 
to colic. 



CONSTIPATION 



123 



1. Dkfk'ient Motor Activity may be (hie to: — 

{a). Weakness of the Intestinal Musculature. — When constipation has existed from 
infancy, especially if it is present in several members of the family, it is hkely to be due to 
congenital hypoplasia of the intestinal musculature. Constipation develo])ini; gradually 
as old age approaches is generally due in part to senile intestinal hypoplasia. When 
constipation occurs in ehlorotie girls, in cachectic conditions, in rickets, and in fevers, 
it may generally be assumed to be due to weakness of the intestinal musculature secondary 
to these conditions. 

When tlie abdomen is constantly distended and tympanitic, and the patient eomphiins 
of attacks of colic, which are relieved by the passage of flatus, it may be assumed that the 
constipation is due. in part at least, to the incapacitating effect of distention on the intestinal 
musculature. The Fl.vtulexce (p. 240) may be primary, or it may be secondary to the 
constipation, in which ease some other cause of the condition must be looked for. 



\ . 


/^ 




!" 


/ / ( iT^ 


«;:;;ig^ 


^1 


1 
\--- 


AC IIV)^ 


^=-^^y^ 


-W 


I" 




mf: 


3 


T 

R 


H^ 





nu[iiiiei>, til tlii^ uiiU tile jollowiiit; liitures, reprt^eiit tint 
houni lifter a bi.'itnutli IireukfjLst at vvliich the (lifFereiit parts 
of the colon are reached, c CaM-uin: AC. Asceiidiiiij colon; 
HF. Hepatic flexure; SF, Splenic rlexnrc ; DC. Iireceii.lint- 
i-i.li.ii ; ic. lliiu' colon; PC, I'elvic colon; R. liecluni 
U. I nihilicus : p, l'elvi..<. 




J-'iij. ^t'K — I'ost-dysenteric atony and pare-is of the colon. 
Compare the lumen of the colon and the slow passive of 
fieccs through it with Fig. 49. 



The consti|)ali(in of Inl |m(i|iIc is due In |i;iil Id Ihe iiunicuiicy of llic iiitcsl iii:il 
musculature rcsulliiig fr<iiii hilly iiilill r';il imi. 

In some of these conditions atoii\ nl llic ciiUiii can be recognized with the .i-rays by 
its :ibnorm!'illy large lumen. In addition to llic sluw passage of heees {Figs. 4i) and ;)0). 

(/'). Deficient Reflex Activity of the Intestines. 

Iiisiilliciciit Sliiiiiildlioii (if Iiifcslhiiil Miirniu Ills. Careful eni|uiry slidiild be m;icle iulo 
the palieiil's ilici ;iiid linbils. as many <:tses are due to too little food biiiig liikeii. or to 
the food eonttiining too lillle meelitinleal or chemical peristaltic stimulants, and some are 
due to ilelieieul exercise. Other ("ises result from a "greedy colon." the absorption of 
food being nniisn;illy coinplilc. In sjiilr iil' cnungli Imid of ;i suHicifntly stimulating 
character bi-ni'.' I;ikcn. :ind In spllr nl llic lacl lliiil llic- ;ilid(initii is nlr;icted and no 
aeeumuhilion of faeces ciin he lill in litlicr the eiildii cir tlic rcctuin. yet a very delieicnt 
<|Uantity nf fa-ces is exerilcd. This is the type df c;ise in which beiulit results from the 
use dl' iigar-agar or jietroleum. In eonstipiition due to ;iii unMiihihle diet or Id a greedy 
(iildii the stools are generally small, dark, and di\. :incl siiiclj less slriiiigl\ lh:in normal. 
In Msophagcal or pyloric obstruction eonstipatidii is ;ihv;iys priscnl owing In Hie sniiill 
• luantity of food-residue which rciichcs the colon. The other symptoms generally prevenl 
a mistake in ditignosis being made: but oeeasiontdly in pyloric obstruction the palienl 
eonililiiins df iidtliing but vome slight indigcstiiin nr weakness in itdditiim to the eon- 



124 



CONSTIPATION 



stijjation. The passage of a stomach-tube twelve hours after a large meal, when the 
stomach should be completely empty, and an a;-ray examination, will clear up the diagnosis 
in doubtful cases. 

Deficient Sensibility of the Intestinal Mucous Membrane. — This is the probable cause of 
the constipation when there is a history of excessive tea-drinking or of the long-continued 
use of large doses of aperients ; it is also partly responsible for the constipation associated 
with catarrhal colitis — in which excess of mucus is passed with the stools — whether 
this is primary or a result of constipation due in the first instance to some other cause. 

Depression of the Nervous System. — In neurasthenic, hypochondriac, and insane patients, 
the condition of the nervous system is the chief cause of the constipation which is almost 
invariably present : but an improper diet is generally an additional factor. 

(('). Inhibition of the Motor Activity of the Intestines. — This group of cases can 
often be recognized by the fact that sedatives, such as opiinn and belladonna, give relief, 
whilst purgatives are required in unusually large doses, and produce an unusual amount of 
colic unless given with a sedative. The ,r-rays show that the small intestine as well as the 
colon is traversed slowly ; this is unusual in other forms of consti])ation (Fig. ,51 ). Inhibition 
may be direct, central, or reflex. 




Fig. 51 — Constipation due to lead poisoning. The passage 
lirougli the small intestine as well as the colon is slow, owing 
u tlie inhibitory action of the splanchnic nerves. 




Direct Inhibition in Lead Poisoning. — The diagnosis is suggested by the occupation of 
the patient, a blue line on his gums or other symptoms of plumbism (p. 34). 

Central Inhibition. — A history of a recent shock or worry is obtained. 

Reflex Inhibition. — Constipation is a frequent symptom of painful diseases of abdominal 
and pelvic viscera, other than the intestines themselves. It can then be cured only by 
treating the primary condition, so that it is essential to ascertain the cause of the pain. 
Constipation is particidarly liable to result from disease of the ^•crnliform appendix, female 
genital organs, stomach, duodenum, and gall-bladder. 

((/). Irregular Spasmodic Contraction of the Intestine : Spastic Constipation : 
Enterospasm. — AV'lien constipation is associated with pain. es])(cially if the pain conus 
in attacks during which the difliculty witli the ijowcls is increased, the possil)ility that It 
is due to spasm of the colon must be considered. The pain is situated in the course of the 
large intestine, most frequently in the iliac and pelvic colon, but occasionally in other parts. 
The affected parts of the colon can generally be felt as a contracted, tender cord, in which 
scybala may be detected and the narrow lumen can be recognized with the a-rays {Fig. 52). 
\Vlien the pain is in the right iliac fossa ap])endicitis may be simulated : the long duration 
of the attacks without any pyrexia, the occasional history of similar pain on the ojjposite 
side, and the contracted condition of the ascending colon and sometimes of the ca>cum 
(though in other cases the caecum may be distended and tympanitic), are distinctive features 
of spastic constipation. When the pain is in the left side, a tumoiu- of the descending or 



CONSTIPATION 



1-25 



iliac colon may be suspected : the long history, the absence of visible or palpable peristalsis 
and of distention above the contracted part, and the absence of occult blood from the 
stools, are ])oints which distinguish spastic constipation from cancer of the colon. In cases 
of spastic constipation the stools should always be examined for mucus, as the spasm, 
especially when it occurs in neurotic women, is often only a symptom of muco-membranous 
colitis, shreds or membranes of coagulated mucus being passed by the patient (p. 398). 



2. Constipation due to Excessive Force required to carry the F.bces to the 
Pelvic Colon may be due to : 

(a). Obstruction by Faeces. — Dr>% hard fa-ces, which require abnormally strong 
peristalsis to carry them to the pelvic colon, result from : (i) Insufficient consumption of 
water — a common cause of constipation in women : (ii) Excessive loss of water by other 
channels — one cause of the constipation of diabetics, and of individuals who perspire freely 
and arc only constipated in hot weather. 

(h). Narrowing of the Intestinal Lumen. 

Organic SIrictiire. — Unless this is due to a palpable tumour it may be very dilliciilt 
to distinguish from consti- 
pation due to less serious 
causes. More or less colic 
is generally present, and 
its situation often gives a 
clue to the localization of 
the obstruction. .Vn .r-ray 
examination, when tlie 
barium is given by mouth, 
rarely gives any lul]) in tin- 
early stages of the disease, 
although occasionally the 
actual narrowing of the 
intestine is observed and 
stasis occurs in the proxi- 
mal portion of the bowel 
{F i 'J. ;>;5). M u eh m o re 
valuable information can 
be gained by the adminis- 
tration of a barium enema. 
Six ounces of barium sul- 
phate arc suspended in a, 
|)iiU and a half of water to 
which has been added an 
ounce and a half of acacia 
mucilage and an ounce of 
mctliylateir spirits. The lluid is run 
of one foot. In normal individuals 




Fuj. O:;. .SkiiifeTiUil to show 
last ii or 4 inches of the traiwv 
stricture of thit; exuct portion of tl, 
riiLture of tlie condition wn,s finite unsuspected 
employed : gastric trouble, possibly an ulcer, 



ul bi^uiuUi by a malignant stricture of tlic 

colon. At the subsequent operation a very lianl 

rcrae colon was found and e.Kcised. Tlic 

til bismuth and the jr-rays wcro 

tliouf,dit probable previously. 

colon twentv-seven hours 

slaii Holland.) 



lowly into the bowel from a funnel at a pressure 
rne of It reaches tlie ea'cuin almost imnicdiately. 
hut even in the early stages of organic obstruction tlie passage is more or less obsl niclcd 
at the seat of the stricture, owing apparently to a superadded spasm. 

Xoii-mdli/imiiil .slrirtiirrs of the colon are rare. If tlicic is a history of tuberculous or 
dysenteric uleeralioii. the possibility of obslruelioii due to eicalri/alion shouki be eon- 
sidircd. tlioiigh this is a very unusual oeeurrenee. Hyperplastic tuberculous infiltration 
of the iiiteslinc. <spccially of the cacum. causes obslruelion, but the tumour present is 
• lillieull to disliMLiuish from cancer. Obstruction to the iliac or pelvic colon may follow 
till' piiicniilis wliicii rcsiills from the formation of diverticula in old ])cople who have long 
siiirereil Ikiim corisliiial ion. This condition may also be indistinguishable from a growth. 
i)ul the possibility should lie borne in mind in the case of elderly patients with a tiunour 
in the iliac or pel\ ie colon, where there is a long history of constipation : the sigmoidoscope 
may help in the diagnosis. If a \(sico-colic listula develops in association with elironie 
constipation, it should be remembered that |)ericolitis due to ulceration of ilixerlieula is. 
a more frccpient cause of this condition than cancer. 



126 



C'OxXSTIl'ATlON 



'■'^■'■m 






Organic stricture of the colon is most commonly due to cancer. The possibility of 
cancer should always be considered when an individual above the age of forty, whose bowels 
have been regular previously, develops constipation of increasing severity without change 
of diet or habits, or when a patient, who is habitually constipated becomes more so without 
obvious reason. The constipation is at first intermittent and may alternate with diarrha-a ; 
drugs become steadily less effective, and enemata, which at first give greater relief than 
drugs, also lose their effect slowly. A tumour is often not palpable, but an examination 
under an auccsthetic reveals the presence of one in many doubtful cases, especially in fat 
individuals. The tumour may vary in size, and even disappear after the bowels have 
been opened well, because a mass of heces may become impficted above a cancerous stricture 
which is itself impalpable. Hence, although the presence of a tumour is an important aid 
in diagnosis, its absence or disappearance docs not exclude the possibility of cancer ; only 
when its disa])pearance under treatment is accompanied by complete and lasting cure of 

all symptoms can cancer be excluded. The 
tumour is hard, and cannot be altered in 
shape by pressure, as is the case with fa?cal 
Umiours. Slight attacks of colic occur fre- 
(|uently, but they are not often severe until 
I he obstruction is almost complete ; the colic 
may bo accompanied by visible and palpable 
piristaKis and spasmodic contractions of the 
intestine. The latter is a most important 
sign, as it never occurs in colic associated with 
lead-poisoning or colitis, and very rarely with 
obstruction due to fa?cal impaction. Progres- 
sive loss of weight and strength, anorexia, 
and ana-mia are late .symptoms, and it is im- 
portant to make a correct diagnosis before 
they have appeared. The obvious presence 
111' blood in the faeces is an important symptom, 
but it is often absent. Much more frequently 
I races are found which are only recognizable 
l)y chemical tests (p. 81). In the absence of 
liicmorrhoids and of lucmorrhage from the 
mouth, throat, or nose, the presence of 
' occult ' blood in the fseces is strong evidence 
that ulceration is present in the stomach or 
intestines ; when symptoms pointing to gastric 
or duodenal ulcer and gastric carcinoma are 
absent, and constipation is present, a suspicion 
of cancer of the intestine receives important 
confirmation. In doubtful cases a sigmoido- 
scopic examination should be made, as cancer 
is much more common in the rectimi and 
])elvic colon — which alone can l)e investigated by this method — than in any other part 
of the intestine. 

A kink of the colon is a very unusual cause of constipation. It is sometimes partly 
res]5onsible for the constipation which is almost always present in visceroptosis {Fig. 56), 
and it should be suspected when an attack of localized iieritonitis. due particularly to 
disease of the female genital organs, appendicitis, or Uakage Irom a gastric or duodenal 
ulcer, is followed by constipation. An a-ray examination should, liowtver. always be 
made before advising surgical treatment, as, in the vast majority of cases, even if adliesions 
are jiresent they have nothing to do with the obstruction. The a?-rays show whether the 
delay takes place in the neighbourhood of the supposed adhesions, and the presence or 
absence of adhesions can also be ascertained by seeing how movable tlie colon is, and 
whether the two limbs of the various flexures can be separated from each other. 

^Vhatever may be the primary cause of Hirschsprung's disease (wrongly called " con- 
genital idiopathic dilatation of the colon "), it is probable that a kink is produced after 




Fhj. :. 1. -Tlie same case ns Fig. JS. Skiattraii i i.lt.T 
tlir* ailriiiiiistration of a bismuth enema seven days 
after Insiimth had been given by the moutli. Arrest 
of the bismuth by the obstructive carcinoma at the 
end of the transverse colon. TC. Food still in tlie 
dilated transverse colon seven days after it had been 
<,'iven by mouth, s, Splenic flexure : Comiilete 



the (iihitation has reached a certain (iegree by the ovcrlian<>in})' of the dilated part of the 

colon over the undilated section {Fig. 55). There is always a history of constipation dating 

from the first few months of Mfe. although sometimes the bowels may be opened daily but 

insuflicicntly. Soon after birth the abdomen becomes 

irreatlv enlarged, the siz.e varying from time to time. 

The outline of the distended colon can be seen, and 

peri.stalsis is often visible. The abdomen finally 

becomes enormous ; it is then tense and tympanitic. 

Attacks of obstruction are liable to occur, and death 

takes place most frequently between the ages of 

three and eight. 

When a large abdominal tumour is present, con- 
stipation may be due to its pressure on the colon. 

Clironic intussusception may cause symptoms 
similar to those produced by a stricture : attacks 
of colic accoin])anied by visible peristalsis occur 
with increasing fref|uency and severity, and they 
are often brought on by food or aperients. An 
intvissusccption should be suspected under the.se 
circumstances when a sausage-shaped tumour is 
l)alpable, es])eeially if blood and mucus are pas.sed 
at fre<|uent intervals. In one-third of the cases 
the a|)ex of the intussusception can be felt on 
rcctMl cxaniinalion. 




Hu-^chslJi 



Dl Pisr AC Vm 


cnditit, colon TC ii 


<olon DC DeM 


pnihtu tolon IC Hi 


PC I oop of pch 1 


L colon R Rettiim 


it pehi rectal ]ui 


ictiOM Tin .lotted hr 


sent the co*ital m 


argm^ 



C— DIA(;X()SI.S OK TIIK t Al SK OF I)VS( IIKZIA. 

l)>sche/.ia is due to a want of proper proportion between the jjower of expelling the 
fares from the pchic colon and rectum, and the force re(|uiretl to do this completely. 
It may lliereforc be due to (1) hi<jjicicnt Dejaration ; or (2) An Obstacle to KJJicicnt 
l)cj'((i(ilion. 

1. l.NF.Ki-KiKNT Def.ecation may be due to: — 
(a). Weakness of the Voluntary Muscles of Defaeca- 
tion, Tliis should l)e suspected when coiisliiialidii dales 
V. from prcgnanev. or is associated with ascites, large 

abdominal tumours, or obesity. It is often easy to 
ascertain the condition of the abilominal nuisclcs by 
simple palpation in the horizontal position : the dis- 
eov<-ry of a movable kidney or a dropped liver would 
also suggest that the abdominal muscles are weak. 
The patient should next be told to raise her head from 
tlie couch : the recti iiuisclcs contract and their strength 
can lie asccrlaiucd, aiwl ;iny separaliciii between them 
rccoyiii/.cd. I''irially. I lie |i:itirril sliould be examined 
standing up : bulging of the abdomen below the um- 
liilicus {Fig. 5(i) shows that visccropto.sis is ])rcscnt and 
that the abdominal muscles are weak. Tlie patient 
(irieii complains of abdominal discond'ort, which is re- 
lieved by lying down or by pressing the lower part of 
I lie abdomen upwarils. In all cases in which a woman, 
whose bowels ha\c previously been regular, becomes 
constipated after the birth of a child, the condition of 
the jielvic lloor should be investigated, as well as that of 
the abdominal wall. The anus is iiornially slightly re- 
Iracteil : the retraction is iiiereaseil and the anus moves 
slightly forward when the levator aiii iiiiisclcs are con- 
cled by making the iiioveinenl wliieli is reipiired ulieii it is attempted to restrain a 
iiriieiieiiig dcfa'calion. 11 thev are weak, the retraelion in the condition of rest is 




:roittosi.-i. 



128 CONSTIPATION 

absent or diminished, and on contracting tlie levator ani muscles, the retraction and 
forward movements are slight or absent. On straining, the whole perineum projects 
much further than it should do, and in severe cases the uterus may be more or less 
prolapsed : in such cases no further evidence is required to show that the dyschezia is 
partly due to weakness of the levator ani muscles. 

When constipation is present in asthmatic or very emphysematous people, it is partly 
due to the fact that the great rise in intra-abdominal pressure required in deficcation 
cannot be produced by contracting the diaijhragm. as the latter is already almost as low 
as it can go. 

(b). Habitual Disregard of the Call to Defaecation. — When dyschezia is not 
associated with weakness of the muscles of the abdominal wall or pelvic floor, the history 
will generally show that it has resulted from habitual disregard of the call to defaecation — 
a very common cause in girls, and a not uncommon one in schoolboys and business men, 
who allow themselves too little time between getting up and beginning the day's work. 
The call is also often neglected if for any reason defsecation is painful. 

(f). Unfavourable Posture during Defaecation. — Enquiry should be made as to the 
height of the seat in the water-closet, as when this is too high it is impossible to assume the 
proper crouching position, and defalcation may consequently be inefficient. Weakness of 
the voluntary muscles of defalcation, habitual disregard of the call, and the assumption 
of an unsuitable position during the act, all lead to the same results — the loss of the defalca- 
tion reflex, and atony and paresis of the musculature of the pelvic colon and rectum. The 
loss of the defaecation reflex is shown by the fact that the jjatient never experiences a desire 
to defaecate, even when examination shows that the rectum is full of fa'ces. The atony 
of the rectum is shown by its abnormally large size and the very slight resistance offered 
when the finger presses upon its walls ; the atony of the pelvic colon is shown by the 
abnormally large .shadow it forms when examined with the ,i-rays (Fig. 48, p. 122). The 
paresis of the pelvic colon and rectum is shown by the patient's inability to dehecate by an 
effort of will, when the rectum is full of fa'ces. 

(d). Primary Weakness of the Defaecation Reflex. — This is sometimes the cause of 
constipation in infants : it is probably the case when defalcation occurs on exaggerating 
the natural stimulus by the mechanical effect of the introduction of a finger into the rectum, 
or by the combined mechanical and chemical effect of the introduction of a piece of soap. 

(e). Organic Nervous Diseases. — When constipation occurs in the course of organic 
nervous diseases, such as lubes dorNdlis. nn/clilis, or »ieiiingitis, it is due to disturbance in 
the defffication centre in the lumbo-sacral cord or the tracts connecting it with the brain. 
When constipation and difficulty in micturition appear simultaneously, the possibility of 
some organic nervous disease should be considered, even if no other symptoms are present. 

(/■). Hysteria. — When dyschezia occurs in nervous individuals it is often due to the 
patient having suggested to himself that he cannot open his bowels at all, or unless he takes 
a purgative or an enema. The diagnosis can be confirmed by the result of treatment : 
if such a patient can be persuaded after a thorough examination that there is really no 
reason whatever why he shotdd not obtain a daily action of the bowels without artificial 
aid, he will have no difficulty in curing himself at once. 

2. Obstaci.es to Efficient Def.ecatign may be due to : — 

(a). Hard and Bulky Fseces. — When the faeces are abnormally hard as a result of 
intestinal constijiation or t>f the excessive loss of fluid from diarrhoea, hemorrhage, or other 
cause, the force required to expel them may be so great, especially if they are bulky, that 
dyschezia results. This condition can be recognized easily by a rectal examination, which 
shows that ficces of abnormal hardness are impacted in the rectum. 

(b). Spasm of the Sphincter Ani. — When defa-cation is painful it is rendered difficult 
as well by reflex spasm of the sijhincter ani. The anal canal and rectum should be examined 
after the introduction of a cocaine suppository, or if necessary under a general anaesthetic, 
so that any local cause of the pain, such as an anal ulcer or inflamed hicmorrhoids, may 
be discovered. In the absence of these, the genito-urinary organs should be examined 
thoroughly for reflex causes of spasm. 

(c). Organic Stricture of the Rectum and Anus. — In every case of constipation a T 
digital examination of the rectum shoidd be made, and in cases of doubtful origin the rectum 
and pelvic colon should be examined with a proctoscope and sigmoidoscope. Congenital 



CONSTIPATION 129 

narrozvness of the anal canal is recognized easily : it is rare, but may give rise to no symptom 
until several years after the child is born. Fibrous stricture of the rectum is an occasional 
cause of dyschezia, especially in women ; it results from inflaminatory infiltration of the 
submucous tissue secondary to infection of an abrasion of the mucous membrane. The 
condition is generally painful, and often associated with active inflammation and ulceration ; 
it can be distinguished readily from malignant stricture by means of the proctoscope. 
('(i)icer of the rectum or pelvic colon is a conunon cause of dyschezia : when constipation 
develops after the age of forty without any obvious cause, especially if it is accompanied 
by a sense of fullness in the rectum and of incomplete relief after defaecation, by loss of 
weight and strength, or by discharge of mucus and blood, the possibility of cancer of the 
rectum should always be considered, and a thorough examination made by the flnger and 
proctoscope or sigmoidoscope. 

{(I). Pressure on the Rectum from Without. — Pressure on the pelvic colon and 
rectum by ti gravid uterus always ]iroduccs sonic dyschezia. Apart from this the possibility 
of a pelvic tumour, such as distended tubes, cancer, or fibroid of the uterus, and ovarian 
tumours, should be remembered in dyschezia occurring in women, especially if there is any 
pelvic pain. A retroverted but otherwise normal uterus cannot be regarded as a sulHcicnt 
explanation of dyschezia. 

(e). Invagination. — When a constijjated patient, whose general health is so good that 
cancer seems improbable, complains that after deliccation he feels as if something were 
still [)rcscnt in the rectum, especially if mucus and occasionally a little blood are passed, 
the dyschezia may be due to obstruction caused by the invagination of the mucous membrane 
of the up[)er part of the rectum into the lower part. The condition is generally a.ssociated 
with lumbar pain. The invaginated mucous membrane can be felt on digital examination, 
especially when the [laticnt strains. 

II. ACUTE CONSTIPATION. 

.\cutc const ipalidii may be (A) Due to acute iiitestiiial ol>structioii : or (H) .1 sifuiptom 
of (a) some general disease, or (li) some other acute alxlaunnid disease. 

.1.— ACITE INTESTINAL OISSTKICTION. 

1. Tiic foilowiug points help in the distinction between acute intestinal obslruclion 
and severe cases of a( iilc constipation of other origin : (i). I'isible and palpable peristalsis 
or stiffening of the iiilcslirus is never present except in obstruction, (ii). Vomititig is never 
f:rciilcnl, except occasionally at a very late stage, ill iion-ol>structi\e cases, (iii). In other 
conditions llic coastijiidi(ni is incomplete : 

(a). I'Matus. and cs'cn a small <|uantily of l;cces, may be i«isscd spontaneously, 

(b). A purgative may give a result ; it is, however, very unwise to administer purgatives 
ill such cases, but frei|iiciitly the patients have already tried them on their own responsibility. 

((■). ,\ rectal examination should always be made. In organic intestinal obstruction 
tlic rectum is empty : if it contains fa'ces there may be obstruction due to fa-ces, but it is 
exceedingly rare for this to prorliicc symptoms at all comparable in severity with Ihosc 
due to acute obstruclioli. Willi this exception, I lie prcMiici- otaiiN (|iiaiility ol laces uould 
show that there was no intestinal obslruclion. 

(d). In doubtful <'ascs two eneiiiala should be yixni. willi an inlrrxal oi an iioiir : 
llii- lirst gcneriUly brings away a certain aiiiounl ol l^icis. cmii M ohsl riiclioii is coinplele : 
the second only rcsulls in the passage of laces or Mains if llierc is no coinplele olislriiction. 
or if Hie obslruclion is liigli in llie small ililcsliiie. If there is eomplcle olislriielion the 
second enema is eillier retained or escapes unallcrcd and with abnormally small force. 

2. Heioic considering any oilier possibility, all the hernial apertures should be 
exaiiiiiicd. even in the absence of local pain, as a slranguhded hernia gives all the signs ol 
aeulc inlc^l iiiiil rjhsl riiel \i,\\. 

■■',. 'I'lir I'olicjwirii: |ioiiils should he considcicd ill del i riiiinilig llic cause u\ Hie aciile 
ililesljiial obslnielioii : 

(i). .\gc. Inlcslinal obslniclicjii in Hie ncH-lMirn is ■a\ si invariably due lo a coii- 

geiiilal malformation: as this isginnally in Hie icclnni (p. .">H(i) Hie latter should bccxaniincd 

u 9 



-J30 CONSTIPATION 

first and onlv after it has been found to be normal should the possibility of congenital 
obstruction in the duodenum or ileum be considered. In infants the conmion cause of 
intestinal obstruction is intussusception ; at a somewhat older age obstruction may arise 
in connection with a Meckel's diverticulum ; but in children and young adults the most 
common cause is obstruction by bands or adhesions resulting from local peritonitis, due to 
appendicitis, tuberculous peritonitis, or caseous mesenteric glands. Acute obstruction 
occurrincT in an infant or child under ten years of age, in whom there is a history of con- 
stipation and abdominal distention dating from soon after birth, is most probably due to 
Hirschspruno-s disease (p. 12C). After the age of forty the possibility of cancer of the colon 
should always be remembered, and in fat patients, especially women, obstruction by 
gall-stones. " In patients over sixty acquired diverticula of the colon are likely to give rise 
to symptoms and signs which are generally mistaken for cancer. 

(ii) History.— A previous attack of appendicitis, or a history of tuberculous peritonitis, 
or of inflammatory pelvic disease in females, suggests the possibility of obstruction by 
bands or adhesions ; the same diagnosis should be considered if the patient has some ^^-eeks 
or months before had a strangulated hernia reduced. A history of biliary colic or of the 
less striking symptoms which may result from cholelithiasis indicates that obstruction may 
be due to impaction of a gall-stone. When acute obstruction follows a period of increasing 
constipation in middle-aged patients, cancer is probably present. 

(iii) Slate of tlir /i-nic/.s.— The passage of blood and mucus without any ficces is very 
suggestive of an intussusception. In older patients it may be due to cancer. The passage 
ofVtools during the early stages, in spite of other evidence of obstruction, indicates that 
the latter is situated in the small intestine, 
(iv). Abdominal Examiiiatioti. — 

(a) Disle»tion.^Gna\ distention generally means that the obstruction is m the colon : 
it it is present very soon after the onset of symptoms, it is probably due to cancer or volvulus : 
if it has been present to a less extent for some time before the onset of acute symptonis. 
a growth is likely ; but if it has developed very acutely, a volvulus is more probable. In 
infants and small children great distention suggests Hirschsprung's disease (p. 126), if the 
abdomen is tympanitic ; if it is partially dull, and if free fluid or irregular masses are 
present, tuberculous peritonitis is the probable diagnosis. Well-marked distention in both 
flanks suggests origin in the pelvic colon or rectum ; if in the right flank only, m the 
hepatic flexure or transverse colon ; if the flanks are comparatively undistended and the 
central part of the abdomen is most affected, the obstruction is likely to be in the ileum or 
the caecum ; distention is slight when the obstruction is in the duodenum or jejunum. 

(b). Visible Peristalsis and Stiffening of the Intestine.— The position and direction ol 
visible peristalsis and the position of stiffening coils of intestine may show the localization 
of the obstruction. When a series of more or less parallel contracting coils is visible in the 
central part of the abdomen, the obstruction is in the small intestine ; if it appears to 
culminate in the right iliac fossa, this is likely to be the seat of disease. Stiffening of a 
length of intestine, which can be seen to rise up and felt to harden, most often occurs in 
the" colon, and especially when there is a growth near its lower end. The most marked 
peristalsis and stiffening occur when acute obstruction is a sequel of chronic obstruction ; 
they may be completely absent in very acute primary cases. 

" (c). Tumour.— The diagnosis of intussusception can be made with certainty only when 
the characteristic sausage-shaped tumour situated somewhere In the course of the colon is 
felt. In acute obstruction due to cancer the tumour is often not palpable, as it is generally 
hidden by the dilated intestine ; but large tumours are felt sometimes, especially when 
present in the right or left iliac fossa : the former are generally due to cancer of the csecum, 
the latter to cancer of the iliac colon and inflammatory thickening round acquired diverticula 
—a condition which may closely simulate cancer. Gall-stones can hardly ever be felt. 

(v). Rectal Examination. — A growth of the rectum can be recognized easily, and some- 
times a growth of the pelvic colon can be felt through the front wall of the rectum. In 
infants, the end of an intussusception may be felt in the lumen of the rectum, and 
more frequently the tumour can be felt on bimanual examination. Obstruction due to 
pelvic adhesions can often be recognized by the presence of tender masses and the fixity 
of some of the pelvic viscera. The presence of more than traces of faces in the rectum 
in cases of undoubted obstruction indicates that its situation is probably high u]) in the 



CONTRACTIONS 131 

small intestine. A very ballooned rectum suggests obstruction high up in the rectum or 
in the pelvic colon, but this is not an invariable rule. 

(vi). Pain. — When the jiain is localized, or moves in a delinite direction to reach its 
greatest severity at a certain j)()int, the latter is likely to be near the seat of the obstruction. 
When the pain is situated in the middle line, the obstruction is probably in the small 
intestine if it is above the umbilicus, and in the colon if below. 

(vii). Vomiting. — The more frequent the vomiting and the earlier the onset of f;eculent 
vomiting, the higher in the intestine is the obstruction likely to be. It is most severe in 
small intestine obstruction due to bands or internal hernia : its onset is later and its occur- 
rence less frequent and sometimes only after food in cases of growth and volvulus. 

(viii). Borborygmi are sometimes most marked over the seat of the obstruction. 

(ix). Shock and Collapse are more marked the higher the obstruction. They are also 
much greater when obstruction is accompanied Ijy strangulation owing to bands or hernia 
than when strangulation is absent, as with gall-stones and cancer. 

B. SYMPTOM.VTIC. 

In Acute General Diseases. — Constipation beginning acutely is a frequent symptom 
of a large variety of acute infective and other diseases. It is never so severe that it cannot 
be overcome by purgatives or enemata, and the other symptoms are so much more striking 
in the majority of cases that the presence of consti|)ation has Httle iiilluence in forming a 
diagnosis. 

In Acute Abdominal Conditions. — Constipation is a prominent symptom in most acute 
abdominal conditions. Other symptoms are often so well marked that the question of 
intestinal obstruction hardly arises. Thus, the diagnosis can generally be made by the 
early tenderness and rigidity, its localization, and the early pyrexia in acute peritonitis due 
to a|)pendicitis or the perforation of an ulcer ; the characteristic situation and radiation of 
the pain in renal and biliary colic, and the frequent hfematuria in the former and jaundice 
in the latter : the presence of a timiour when an ovarian cyst is twisted ; the meliena and 
occasional hu-matemesis. and the presence of a primary disease in the heart or abdomen 
in 7ne.ienteiir cinholisni and tlironihosis respectively. Some cases of acute pancreatitis are 
clinically almost indistinguishable from intestinal obstruction, but flatus is generally |)assed : 
there may also be a history of biliary colic, and the patient is generally fat, middle-aged, 
and alcoholic. The diagnosis is seldom made with certainty until the typical fat-necrosis 
is seen on opening the abdomen. In lead colic (he constipation is not absolute, and the 
occupation of the patient and the blue line on Ihe gums (p. 34) suggest the correct 
diagnosis. Arthur /•'. Hertz. 

CONTRACTIONS, Athetotic, Choreiform, Fibrillar, Spasmodic, and Tetanic^ 

ar( all to be delined for present purposes as involuntary and i)ainless contractions occurring 
in the voluntiirv nmseles. I'Yom Conth.xctitiik.s (p. ];J8) they may be distinguished by their 
short duration, longer or shorter intervals in which the affected muscles are relaxed occurring 
between t^he separate contractions. From cramps they differ by being painless, or com- 
paratively so, and also by their sh(jrt duration. IJut in many cases it is impossible and 
also unceessary to draw any hard-and-fast line showing where, for example, tetanic 
contractions cease and tetanic cramps begin. In all eases Ihe occurrence of the contractions 
mentioned mIxinc immn he taken to indicali- soriii- iliseasr of Ihe nervous system, usually 
organic hut suriicl inics tunclional. 

ATHETOTIC CONTRACTIONS, ATHETOSIS, OR MOBILE SPASM. 

.\thetosis is a I'oru) of in\-oluntary movement alTceting the lingers, hands, and 
wrists most often : less often the toes and feel, anil in rare insl.anees Ihe lace. It is 
usnallx- unilateral, but in exceptional eases bilateral — Ihe •double athetosis" of l''reneli 
nciiriilogisls. The movements arc sjjontancous and inecssiint, and may even continue 
while the pal ieiil is asleep ; in other instances they tend to cease, but are started anew <>i' 
exaggerated when voluntary movement is attempted. In the hand, the moveinenis eonsisi 
of a succession of slow and serpentine llexions, extensions, hyperextensions, and lateral 
motions, all eotnbincil In cause Ihe tinixers and llinnih lo cxeenle Ihe ninst curious and 



132 



CONTKAfTIOXS 



complex cliitchinii- or spreading movements (Fig. 57). The wrist is held more or less flexed : 
the fingers may move about together, or wander each individually. Analogous movements 
are observed when athetosis occin-s in the lower extremity, or the mouth and face. N*) 
great regularity characterizes the motions of athetosis ; as a rule they are steady rather 
than violent ; a large amount of voluntary control over the affected parts is retained. 
Mobile spasm is due to varying degrees of central irritation of muscles that are incom- 
pletely paralyzed and somewhat spastic. 

Primary, idiopathic, or primitive athetosis is a rare disease of childhood or of adult life, 
in which bilateral athetotic contractions first make their appearance in a previously healthy 
person, either for no particular reason, or after a chill or a nervous shock. It may be 
associated with epilepsy or insanity. This form appears not to be connected with any 
gross changes in the nervous system, thus diflering from all other conditions in which 
athetosis is seen. 

Athetosis is conmion in the various sj>aslic paraplegias of in{a)its and children, whicii 
may be either congenital or aciiuired : in Congenital cerebral diplegia, also known as 
Little\s disease wlien the legs are affected chiclly. the ncr\<ius structures suffer from an 
inherited taint (alcoholism, syphilis, insanity), and either fail to dexclop properly, or 

degenerate early in life. The onset of Little's 
disease is gradual, and usually early, but it may 
be delayed until the child is as much as six or 
eight years old. Tlie patient is backward or 
mentally deficient, probably unable to walk, and 
alllicled with bilateral spastic paralysis. This 
may affect the legs, the legs and arms, or even 
the whole body, and may be more marked and 
more spastic on one side of the body than on 
the other ; speech is defective, optic atrophy 
conunon, and the gait is clumsy and stiff, " cross- 
legged ■ or ' scissor.' Involuntary movements 
occur in the affected members, and are athetotic 
or choreiform ; tremor or intention-tremor is also 
not infrequent. Although it may not appear for 
some years after birth, this is really a congenital 
disorder, and it is to be distinguished, for reasons 
connected with its pathological anatomy and 
etiology, from certain other forms of spastic 
paralysis in infants and children that may closel>- 
resemble it clinically. These are the acquired 
cerebral paralyses of itifanls. the spastic infantile 
hemiplegias, monoplegias, diplegias, triplegias, paraplegias, that result from more or less 
localized cerebral inflammations or lucmorrhage occurring at birth or in infancy. Poren- 
cephaly, or the occiu-rence of lacunae in the tissues of the cortex or brain, may be found 
in cither the congenital or the acquired cerebral paralyses ; it is really a post-mortem- 
room term, and re(|uires no special consideration here. 

Acquired spastic paraplegias fall into two categories, according to their etiology : — 

1. Jiirth palsies : due to meningeal or cortical ha?niorrhage caused by ])rolonged labour 

or the use of instruments. Many of these infants Iuiac been born prematurely. 

2. Ac(pmed jmlsies : due to — 

Encephalitis after an acute specific fever, or infective in origin. 

Polio-encephalitis, the cerebral analogue of acute poliomyelitis in the anterior 
cornua of the cord. 

Cerebral embolism. 

Cerebral or meningeal ha-morrhage or thrombosis. 
The birth palsies are due to injuries received in the process of birth, and the rupture 
of meningeal or cerebral blood-vessels, with the escape of blood ; they develo]) at once, 
and the history of the case should make diagnosis easy. The diagnosis of the exact cause 
of an aciiuired s/iaslic paralysis in an infant or child may be less easy. The jjaralysis due 
to encephalitis generally appears during the first two or three vears of life, but ma\- come 




Fiff. 



CONTRACTIONS 133 

on at almost any age. Cerebral tlironibosis in children is said to happen oftenest at about 
the age of six. Cerebral embolism is likely to be seen in infants or children with acquired 
Ijeart-disease. the embolus being derived from vegetations on the mitral or aortic valves, 
or from tluombi tluit have formed in backwaters of the (lilate<l left auricle or ventricle. 
These infantile hemiplegias or diplegias are of sudden onset, and are characteristically 
spastic. Athetotic movements, with or without choreiform contractions, trophic lesions, 
and tremors, are common in the affected limbs : the children often grow up to exhibit 
mental defect, imperfect speech, or epilepsy. As a rule, the face is less involved than the 
arm or leg, and the athetotic movements, confined to the affected parts, may not begin 
initil years after the occurrence of the original cerebral lesion. 

Post-hemiplegir athetosis, which cannot be marked off sharply from post-heniiplegic 
chorea (see p. 134). is an uncommon sequela of hemiplegia in the adult ; but common — 
being seen in about a third of the cases — in the congenital and acquired hemiplegias just 
considered. In the adult it occurs oftenest when the lesion is situated near the posterior 
l)art of tlie internal ca])sule or the 0])tie thalamus. These athetotic movements of the 
extremities liave been described already : in the adult, they may be combined with 
choreiform contractions involving the whole arm and shoulder, and the face. The 
diagnosis should not be difficult, as the history of a stroke will be obtained and the physical 
signs of a hemiplegia will be present. 

CHOREIFORM CONTRACTIONS. 

These arc similar to the contractions seen in chorea. They are involuntary and inco- 
oidinated movements. )nirposive in character, but aimless and ineffective in performance. 
'I'hey arc jerky, rajiid. and highly irregular; grou]is of muscles are put into action successively, 
as if the original intention were given up. or changed, as soon as the complex movement 
began. They may affect one side of the body only, or both. When mild, they amoimt to 
no more than excessive fidgetiness, involving perhaps only the hands and arms, or the 
hands, arms, and face, in wriggling and grimacing. When severe, they give the patient 
no rest : he is tossed about. ])erhaps with the idmost violence, by combined but irregular 
contractions, in which any of the voluntary muscles may partiei|)ate. t'horeilorni con- 
tractions bear no resemblance to tremors, whether coarse or line. From iiiteiition-tremorx 
they arc distinguished by the facts that they continue when the patient is at rest, that 
they are purposive, and resemble ordinary voluntary movements misapplied. From 
ataxia they arc distinguished by occurring at rest as well as on attempted movement : the 
muscular cfintractions of ataxia are merely inco-ordinatcd. apparently ill-designed and 
clumsily executed, types of normal mo\ements. 

ClinrcirorMi cnril i'mcI inns ai'c' seen 111 I he Idllduing cciiKliliDiis : — 

( Ikiicu iiiiiKii-, or' St. \'itus"s (lance: I I'r'c-lieiiiiplegie chorea: )iost-lienii|)l('<iie 
chronic or limit iiigton's chorea ; chorea j chorea : spastic paralyses of iiilanls ; coill 

major, or iiaiiilcmic chorea: hysteria. ' ciil sclerosis: eliorea eleetrlea (llciioi'li). 

Chorea, clioren niiiinr. iiciilc chunii. or .S7. I' Una's ddtiee. is an acute disease of childhood 
or adolcsf'cnce. conmioner in girls llian boys, and closely comiccted with a history of 
rheumatism, and with rhciunatic endocarditis. Like rheinnatisni. it is often a family 
disease : not infrequently one finds that one or two children in a large rheumatic family 
have had rheumatic fever or rheumatism, anolher chorea, and iiiiotlier both rhcimwitie 
fever an<l chorea. It is commonly and erroneously held that scNcre rriglit may by itself 
be the ciiiise of an attack of chorea. It may also occur in adults in connection with preg- 
naiiry. u lien it is soiiiel inns of a severe Ixpe. :inil may run on iiilo ins;inily. The movc- 
riierils iiia\ he eonlineil to one side of the body heliiieliorea or may alTecl holh sides; 
llic niiiseles iire in general weak, speech may be int<rfere(l with, respiration is often jerky, 
and the patient is often unduly irritable anrl emotional. I'^xccpt in the severest eases the 
iiiovcmenis cease during sleep : the disease tends to recovery in the course of perhaps two 
or iliKc nioiillis. .Mild cases in which the face is most affected may present a certain resem- 
blance to I he more chronic and (|uitc uncomiccted disorder known as habit-spasm, lialiil- 
iliiin-a. or ((iiivalsiju- tic (see Si'.\s.Moi)K' C'onthactions, p. i:il>). A laeial ti<' is controlled 
for a lime by strong efforls of the will, whereas the facial movciiienls of chorea will usually 
lie Irienased liv the eoneeiit rat ion of tin- allinii ii llii in : llie l'aei;il nioxcnieiits 



134 CONTRACTIONS 

of chorea are irregular, representing a succession of various purposive but uncompleted 
actions, while the facial tic consists in tlie repetition of a single definite and purposive 
movement, originally designed, no doubt, to give relief to some local irritation. 

Chro?iic, degenerative, or Huntington^ s ehorea. is a rare hereditary disease coming on at 
the age of thirty or forty, associated with slow and difficult speech and with insanity. The 
involuntary movements are slower and more ataxic than those of acute chorea, and can 
often be suppressed for a time by exercise of the will. They affect the extremities and face, 
are coiiliniious. cease (hiring sleep, and are accentuated by excitement, so that at first sight 
acute chiirea may l)e imitated fairly closely. The diagnosis between this chronic chorea 
and an acute chorea tliat had become chronic, as sometimes happens, would turn on the 
family history, mental symptoms, age at onset, and the course of the disease. Chronic 
chorea is incurable, and may take twenty years or more to run its course : mental failure 
occurs early, and is progressive : and a family history of chronic chorea can be obtained. 

Chorea major, or pandemic chorea, is an epidemic hysterical manifestation occurring in 
the more emotional races of Europe imder the influence of religious excitement. Chorei- 
form movements are among the less conspicuous of its motor phenomena ; it is unknown 
in the more phlegmatic northern races. 

In hysteria the motor plienomena are notoriously i)rotean. Should a hysterical patient 
have had chorea herself, or should she have had the opportunity of observing it in others, 
she may reproduce its characteristic movements with great accuracy. The diagnosis may 
be very difficult for a time, particularly if the patient's previous history be not known, and 
hysteria not suspected. Her temperament will probably lead her to develop other signs 
or symptoms that suggest the true diagnosis ; such as tremors, paralyses, contractures, 
hemi-anaesthesia, anaesthesia of the stocking and glove distribution, exaggeration of the 
deep reflexes, or attacks of hysterics. Remission of the choreiform movements and of the 
local symptoms generally may occur wlien the hysterical patient thinks she is no longer 
imder observation, or when her attention is diverted elsewhere. The hysterical patient 
simulating chorea or hemichorea is likely to overdo the part. 

Choreiform movements may occur in connection with hemiplegia in two forms. Pre- 
liemiplegie chorea has been recorded in a few cases, twitchings or even choreiform move- 
ments beginning in the limbs of one side of the body shortly before the onset of an apoplectic 
stroke. Post-hetniplegic chorea is commoner, and more often seen in children than in adults. 
After a hemijjlegia more or less muscular spasm and movements of one kind or another are 
habitually seen on the affected side of the body. In many patients these movements take 
the form of tremors, fine or coarse ; in others they are athetotic : in others again they are 
ataxic, occurring only when voluntary movements are attempted : and in yet others they 
are choreiform. Wliich of these forms of muscular contraction is likely to occur in any 
given case it is impossible to say ; they are all due to combinations of cerebral irritation, 
muscular spasm, and muscular paralysis, mixed together in varying proportions. 

The clioreiform movements occurring in the spastic paraplegias of infants and children. 
conditions that have been more vaguely described as cortical scleroses on the strength of 
their post-mortem aj>pearances, are to be regarded as variants of the athetotic contractions 
already considered above. Henoch's chorea electrica is considered below : it is the muscles 
of the neck and shoulder that are chiefly involved in this rare disorfler. 

FIBRILLAR CONTRACTIONS. 

Fibrillar contracti(ms of the nuiscles. or fascicular muscular twitchings, are small 
spontaneous movements visible on the surfaces of muscles, rhythmical or irregular, involving 
not the whole muscle, but only single muscular bundles in it. They may be confined to a 
few of the bundles, or may occur irregularly in any of the bundles composing a muscle. 
They are almost always too feeble to produce visible movements at the joints ; they are 
increased in fatigue, and when the muscle is mechanically stimulated. Similar, but coarser, 
twitchings may be seen in normal muscles when tliey are over-fatigued, or on exposure to 
cold. The finest fibrillar contractions are said to occur only in cases of organic disease in 
the central nervous system. They are seen most freely in muscles that are degenerating 
or undergoing atrophy, or are shortly about to atrophy, as the result of disease in the lower 
motor neuron ; they cease to appear when the muscle is much wasted. The\- are most 



CONTRACTIONS 135 

evident in the extremities and tongue, and no doubt are due to irritation of motor nerve- 
cells in the cord or bulb that are hyper-excitable because they are degenei'ating. 

From a diagnostic point of view, fibrillar contractions are important because for 
practical purposes they do not occur in the mi/opathies or primary muscular di/strophies 
that are due to lesions in the muscles themselves and not in the spinal cord. In only a few 
recorded cases have these fibrillations been seen in cases of myopathy where lesion of the 
central nervous system could be excluded. Neurologists and myologists have devoted 
much attention to primitive myopathy, with the result that it has become burdened with a 
highly elaborate classification and nomenclature. Thus the condition generally has been 
described as primary progressive myopathy, progressive muscular dystrophy (Erb), idio- 
jiathic muscular atrophy and hypertrophy, jjrimitive progressive myopathy, muscular 
dystrophy. myo|)athy. 

Special forms of it have been raised to the dignity of ' types." the chief of which are 
the — 

Simple atrophic (Erb) I Facio-scapulo-hiinieral .Mixed and transitional 

Pseudo-hypertrophic | (Landouzy and Dcjcrinc) (Leydcn and Mocbius : 

.Juvenile (Erb) I Distal (Gowers) Zininicrlin). 
Myotonia atrophica 

Distinctions Ijctwccn these various forms must be sought in special manuals. Tlieir 
iniportanoe for present purjjoses consists in this — that fibrillary contractions may occur as 
a rare exception in most of them. 

Contrariwise, librillar contractions are observed habitually in the course of the pro- 
gressive muscular atrophies of neuropathic origin, variously known imder such names as — 
chronic anterior poliomyelitis, amyotrophic lateral sclerosis (Charcot), progressive bulbar 
paralysis, progressive muscular atrophy, toxic degeneration of the lower motor neuron. 
Werdnig-Hoffmann progressive muscular atro])hy of infants, according to their special 
characters. In all of these, the lower motor neurons are [jrimarily at fault, exhibiling slow 
or rapid degeneration ; in many cases the up])cr motor neurons are also alfected, either 
simultaneously, or before or after the lower. As a rule, no cause for the degeneration can 
be discovered ; but many — perhaps a half — of the patients have previously had acute 
poliomyelitis. Occurring in infants or children, this neuropathic muscular atrophy is 
generally of the Wcrdnig-IIolfmann type, affecting the legs first, and spreading upwards 
to the body and arms ; the hands and feet are affected late, and the deep rellexes vanish. 
The condition may at flr.st sight resemble rickets, but in rickets there is no real muscular 
atrophy, the deep reflexes arc retained, and fibrillar contractions do not occur. It may be 
indistinguishable from one of the primary myoi)athies considered above ; but the occur- 
rence of fibrillar contractions would make the diagnosis of neuropathic muscular atrophy 
the more probable. 

In a/lulls I lie disease may conform to one of several types, according to the distributicin 
ol the atrophy. In some instances the lower motor neurons of the hand, arm, and neck 
are attacked, when the Claw-hand (p. 109) may result ; in others, the lower extremities 
may first show the degeneration. Charcot's amyotrophic lateral sclerosis is characterized 
by spasticity of the legs C(imbirii(l with atrophy of the muscles of the hands and arms. In 
making the iliagnosis of ii(uni|)atliie muscular atrophy it must be remembered that the 
onset is gradual, that librillar contractions are present, that the atrophy proceeds pari 
passu with the loss of power, and that sensation and the sphincters are not involved. The 
electrical changes in the muscles are of assistance, too, the partial Ukvction oi' I)kc;i;ni;ua- 
TION (p. ,582) being exiilbited ; the nerves react iiorniMJjy In iMiailiMii. and to galvanism so 
long as there iirc muscle fibres left to respond In llir si iinulal imi. \\liilc liii- nuiseles read 
sluggishly, and .\.C.C. is often greater than K.( .( . 

liiilliar paraljisis is due to lesions of the medulla oblongata, and the nerves mainly 
alTeetcd arc the motor part of the lil'lh. the seventh (facial), the ele\(iilh (spinal accessory) 
and tweirth (hypoglossal). In oilier eases (ipiil lialnioplegia is observed as well. It is only 
111 the chronic cases of biiibai- paralysis thai librillar eontraelions are seen, and they are 
particularly w<ll shown in I lie Inngiie. which lias been ileseiibcd as looking "like a bag hall 
full of worms." The main syinplonis will be dillieiilty in art iiiilation. |)honation. mastica- 
tion, and, most of all, in swallowing. 



CONTRACTIONS 



SPASMODIC CONTRACTIONS. 



In general parlance, the epithet ' spasmodic " implies suddenness and short duration. 
These characteristics are not implied by the word as it is used clinically. Hence it is neces- 
sary to distinguish between spasmodic contractions or muscular sjiasms of three kinds, 
according as they are : — (1) Short and single — the muscular twitch ; (2) Short and repeated — 
doniis or clonic spasms : (3) Tetanie — commonly and imj)roperly known as tonic spasms : 
these ;irc lona-sustaincd. 

Single Spasmodic Contractions of a muscle or group of muscles, over in a fraction of 
a second, may occm- in normal persons who are suffering from great fatigue, overwork, or 
nervous exhaustion. For no apparent reason, and frequently just as the person is going 
off to sleep, a sudden violent twitch in one or more of the limbs occurs, and wakes him up. 
In other cases these sudden starts may occur when the patient is resting by day. In ahnor- 
matii/ neri'oiis or e.rcitaltle patients such sudden spasms are seen more frequently, and often 
result from some sudden and imexpected sensory impression — a sound, sight, or touch. 
The diagnosis of such spasms in nervous or jumpy patients should not be difficult, the 
affection being very chronic, and no doubt familiar to the patient and the patient's entour- 
age. Coming on suddenly, this juiiipiness may be a minor sign of various nervous disorders, 
such as hysteria, acute chorea, delirium tremens, general paralysis, or Graves's disease. 

Single twitches of muscles or of groups of muscles form the outstanding, feature of the 
simpler forms of a series of affections known as liabit spasms or spasmodic tics. A habit 
spasm consists in the involuntary repetition of some ordinary co-ordinated purposive act. 
In many instances the tic was at first a natiu'al reflex act. designed to allay some transient 
irritation. Thus a blinking tic may have been initiated by the pain caused by a foreign 
body in the eye, or conjunctivitis ; a sniffing tic by some temporary itching about the nares, 
or it may be associated with the presence of adenoid growths in the nasopharynx ; a shoulder- 
shrugging tic by some irritation of the neck due to a tight or rough collar. By voluntary 
re|)etition such an act ultimately becomes automatic, when it is spoken of as a habit spasm 
or tic. These motor tics exist in great variety, oftenest affecting the face, less often the 
jaws, neck, or limbs ; they are so common as to escape conunent in their minor manifesta- 
tions — mannerisms and stereotyped acts — being set down merely to • individuality.' 
Most tics can be controlled by mental effort with some distress, are increased by emotion, 
cease during sleep, and are cm-able only with great difficulty when well established. In all 
cases the patient is supposed to exhibit a certain psychical weakness. 

Blore violent and shock-like muscular s]5asnis are seen in the rare condition known as 
myoclonus or paramyoclonus multiplex. Myoclonic movements are particularly sudden 
and violent, occurring bilaterally, or first on one side of the body and then on the other ; 
they are painless, but may give rise to much inconvenience by their violence. They are 
increased by emotion and cease during sleep. They may be single, but more often are 
clonic, repeated perhaps fifty or a hundred times in a minute. In paramyoclonus multiplex 
there are no mental, sensory, or siihincter changes, and this rare disease is described as 
both familial and hereditary. In hi/stcria. myoclonus is seen exceptionally, accompanied 
by other hysterical manifestations. In certain rare forms of epilepsy, the so-called myoclonic 
epilepsy, these paroxysmal asynchronous bilateral lightning-like movements have been 
recorded ; the diagnosis will be easy here, as the patient exhibits the jjhenomena of major 
epilepsy — loss of consciousness, relaxation of the sphincters, etc. — in addition to the sudden 
and forcible myoclonic movements. In certain cases of minor epilepsy, oi- j)etit mal, the 
affection may take the form of spasmodic twitches of the muscles of a limb, or of the face, 
associated with a brief absent-mindedness or a few seconds of loss of consciousness without 
loss of automatic control over the body generally. 

Clonic Spasmodic Contractions, clonic spasms, or clonus, are in reality interrupted 
tetanic contraetions. consisting in the rhythmical and more or less rapid repetitions of the 
single brief imiseular spasm or twitch. .\ typical clonus of muscles in the arms or legs may 
often be produced in health by the adoption and maintenance of some strained position. 
Thus ankle-clonus is soon produced if a normal person sits in a chair and strains the heels up 
while the toes are held pressing on the floor. Such clonus is physiological, being due to 
heightening of the muscle tone or normal state of tonic muscular contraction by the applica- 
tion of mechanical tension to the calf nniscles. 



CONTRACTIONS 137 

Pathologically, clonic spasms are seen typically in tlie second or clonic stage of niiijor 
tjjiltpsfj. where they succeed the initial tetanic (or tonic) stage. Here they are universal 
and bilateral as a rule, although one side of the body may be involved more than the other, 
or the arms more than the legs. Consciousness is lost, and the sphincters are often relaxed. 
Mild and limited clonic .spasms of a few muscular groups, without loss of consciousness 
and lasting for only a few seconds, may be seen in patients with major epilepsy, and are 
often described by them as " warnings.' Such attacks are identical with those of minor 
cpilc|)sy. In certain epileptic patients they seem to be to some extent under control, so 
that their threatened onset can be prevented if the jjatient can sit or lie down, for example, 
or can press on or constrict the limb in which the spasms are about to appear. The diagnosis 
of lii/slero-epilepsi/ is sometimes made in these patients ; but the term is not a good one, and 
is often misleading. Very similar convulsive seizures may be met with in patients with 
clironic nephritis (urcemic convulsions) and in pregnant women (echimpsia). The clonic 
stage of epilepsy may be imitated unconsciously by patients with hysteria, or frankly 
mimicked by the malingerer. In hysteria the onset of the fit is gradual, not sudden ; con- 
sciousness is impaired, not lost ; the pupil reacts to light, and is not immobile as in epilepsy ; 
.screaming and purposive movements occur throughout, and the fit is often protracted : 
the sphincters are not relaxed, and the tongue is not bitten. The malingerer is red and 
heated by the effort of i)roducing the clonic sjjasms, his consciousness is fully preserved, 
and he reacts to painful stinuili that leave the epileptic unmoved. Both the liystirical 
patient and the malingerer show quivering of the eyelids, and are likely to resist atteui|)ts 
to open the eyes. 

In Jacksonian epilepsy, clonic convulsions occur without loss of consciousness : they 
are usually unilateral, starting in some given muscle and spreading thence until both limbs 
or half the body are convulsed. Transient paresis from exhaustion may be noted after- 
wards in the affected muscles. In severe or long-established cases the whole body may l)e 
convulsed, or a tetanic stage may occur after the clonus ; in these instances consciousness 
may be lost. Jacksonian or focal epilepsy may result from any form of local irritation of 
the motor cortex — trauma, ha-morrhage, new growth, the effects of syphilis, chronic inflam- 
niation. It leads in the long run to paresis and atrophy of the affected muscles. 

As the names im])ly. the very rare conditions known as tnyiirloiiiis and piiratiiyiirloniis 
iiiiiltiple.v cxiiibil typical clonic contractions. The elomis occurs in single nuiscles or nuiscle- 
groups, such as the biceps and su]>inator lougus, the (piadriceps femoris and scmitcudi- 
nosus ; rarely in the face : from 50 to 150 contractions a minute may occiu'. Henoch's 
chorea cicclrica is the same as myoclonus. It is said that animals from which the jiara- 
thyroid glands have been removed may exhibit identical sjiasms. For the diagnosis of 
myoelomis, sec above. Clonic spasms of the neck-nniseles, particularly the sternomastoids, 
are common in tiirlirollis or wry-neck. 

Tetanic Contractions, tetanic or the so-called Ionic spasms. Physiologists and clini- 
cians holli niaUc use of the two terms " tetanic ' and Ionic" hnl uid'ortunatcly employ 
llicni in (lilfcicnl senses. Physiological " tetaiuis " is the appMicnIly steady state of 
nuiscnlar conl lacl ion exhibited by the voluntary muscle al work, niainltiincd by I lie fusion 
of separate' nuisenlar twitches or spasms due to a rapid succession of nervous stinndi. It 
may be seen in a single muscle or in many logellui-. Clinically, however, ■tetanus" or 

■ tetanic eonliaclions ' have come to be associated with pain, besides being of some dura- 
tion, and llic lerms arc used only when a large number of muiscIcs are involved sinudta- 
neously : Iclarius of a single nuiscle is referred to clinically as a iriDti/) (p. i:$!) and 150). To 
llie physiologist, the normal resting muscle is already in a slate of " Ionic conlraelion," and 
exhibits • tonus." This nniscle-tone is mainlained partly by local or peripheral stimula- 
tion (mechanical tension, the venosity of the blood, drugs such as digitalis or veratria), and 
partly by nervous impulses that reach the nmseles more or less continuously from the 
motor nciudus of the central ner\ous system. This eenhal elcnienl of muscular tonus is 
ri-:dl\ of i(lle\ origin and due lo poslnre. the inaini enaric<' ol llic ciccl altilndi- : (he inolor 
iiii|iuUrs (Icsccnding in answer lo ascending inipnlsis rcccixcd by I lie ccnl ral iiei\diis syslein 
tidin Ihe nniscles and joints eoneeined. linl llie elinician applies llie terms ■ tonus" and 

■ loriii' conl lacI ions ' lo Ihe se\cre and pathological nuiscular eon I I'liclions seen, for ex;unple, 
in (lie liisl slagc of niajoi' epilepsy, which arc pliysiologieally and seieni ili(all\- speaking 
Ichiuie. iiol loriir. 'I'his clinical misuse of Ihe uord ■Ionic" is wcll-eslablislied and time- 



138 CONTRACTIONS 

honoured, but only serves to promote confusion. The terms " tonic spasm ' and ' tonic 
contraction ' should be reserved for states of muscle-tone that are raised only within physio- 
logical limits, and are not pathological. The contractions or spasms that the clinician calls 
' tonic ' are almost always pathological, and in the interests of uniformity should be 
described as " tetanic,' not " tonic' Exaggerated states of physiological tone and the 
milder degrees of pathologically heightened muscular tonicity are described clinically as 
spastic states or spasticity, falling short of tetanus in degree, and differing from both tetanus 
and cramp by being painless. They are detailed under tlie heading Contractures (p. 139). 
Tyjiical tetanic (or tonic) spasms are seen in teUiiiiis. Here the patient has become 
infected by Bacillus fetani (Plate XX]'III. Fig. T. ]).614), through some known or unknown 
wound. He first notices stiffness of the neck and jaws ; soon, increasing tetanic spasm of the 
muscles of mastication brings on trismus or lockjaw. Spasm of the facial muscles next 
brings on the painful grin known as the risus sardoniciis. and presently paroxysmal tetanic 
spasms of great violence occur in practically all the voluntary muscles, although in mild 
cases in children the spasm may proceed no further than the muscles of the face. If the 
spasms are strongest in the extensors of the back, the body is arched backwards till, perhaps, 
the heels touch the head (opisthotonus). If the flexors contract most powerfully, the body 
is bent forwards (emprosthotonus) ; in some cases the body remains straight and stiff (ortho- 
tonus) when the flexors and extensors are balanced. These acutely painful paroxysms 
last for perhaps a few seconds, and recur at varying intervals on any kind of stimulation ; 
they may cause death by asphyxia or heart-failure. In the intervals between them, a 
milder but still painful tetanic (the so-called tonic) contraction of the muscles is maintained : 
or, in milder cases, nothing more than an exaggerated physiological muscle-tone. In mild 
or chronic cases of tetanus, the signs and symptoms will be far less severe than those 
described above ; but trismus and painful muscular contractions will still occur. In some 
chronic cases, the chief sign may be a recurring but transient risus sardonicus, perhaps with 
some stiffness of the neck ; not a few of these patients have been treated for hahit-spasrn or 
Itj/sterical grimacing for a time, until the suspicion of tetanus arose, or spread of the tetanic 
spasms to the trunk-muscles made the diagnosis more obvious. The diagnosis of tetanus 
may have to be made in other instances from impacted wisdom tooth : or from tnuseiilar 
rheumatism, which may cause stiff-neck but is hardly likely to set up trismus ; or from 
spinal mrningilis, in which there is fever, while the tetanic spasms occur on exertion, and 
do not ]irimarily affect the muscles of the jaws, and great pain is felt on moving the head 
and neck. 

In .'itrt/chnine poisoning trismus is absent or occurs very late, the extremities are 
first and most markedly affected, the nuiscles are tiuite relaxed between the paroxysms, 
and the symiitoms develop rapidly — within an hour or two of the administration of the 
drug. In tetaiiji {]>. 2) the distribution and diu-ation of the tetanic contractions should 
suffice to prevent any confusion with tetanus. In hydrophobia there should be a history 
of a bite by some animal, most often a dog ; mental symptoms are prominent, and the 
spasms affect the muscles of respiration and deglutition most, while trismus is absent. 
In hysteria a patient may exhibit trismus, tetanic spasms, and opisthotonus ; but no true 
picture of tetanus will be presented, and other evidences of hysteria will be found on 
examining the patient, or will develop if the case be kept under observation. 

A. J. Je.i-Bhike. 

TCONTRACTURES — are lasting bodily deformities resulting from a great variety of 

causes. For clinical ])urposes they may be divided roughly into two classes, according as 
they are (1) Aclivc. or (2) Passive. The division is not sharp, as active contractures when 
long established tend to become passive. 
1, Active Contractures: resulting: — 

(a). Fro7n lesions of the upper motor luiiruii : 
Cortical lesions Transverse lesions of the cord Spastic ataxia 

Hemiplegia j .Subacute combined degenera- ; Spastic parajjlegia 

Friedreich's ataxia ' tion 1 Haematomvelia 

Myelitis | Lateral sclerosis j 

(ft). From lesio7is of the lower motor neuron : 
Acute poliomyelitis ] Progressive muscular atrophy I Injury of nerves 

Chronic polioiuyelitis Neuritis 



CONTRACTURES 139 

(f). From disuse : 

Hysteria | Torticollis 

2. Passive Contractures : seen in : — 

Late stajics of the active eontractures 

Local organic diseases of the bones, joints, muscles, fasciae, skin. 

Active or Spastic Contractures. — In these, certain groups of muscles are thrown into 
a state of permanent contraction, or else the balance of power between antagonistic sets 
of muscles is upset. In either case bodily deformity (flexion, extension, curvature) results : 
but the deformity can be redressed temporarily cither by steadily maintained mechanical 
traction, or by the forcible electrical stimulation of the weaker set of the antagonistic 
muscles involved. In passive contractures, on the other hand, no amoimt of electrical or 
other stimulation avails to correct the deformity, nor can the application of force without 
rupture of the tissues. 

Active contractures must be distinguished from certain other forms of muscular 
contractions, particularly cramps and tetanic (or so-called tonic) contractions or spasms 
of the voluntary muscles. Cramps may resemble contractures by their relatively long 
duration — thus tliose of tetany have been known to persist for days and even weeks ; but 
pain is a coiistant feature of cramp, whereas it has no connection at all with contractures 
per se. Telanic contraetions of muscles (see Contractions, p. 131) — commonly called ionic 
by the misuse of a word that already has a definite and different physiological meaning 
(p. 187) — resemble cramps by being painful, and differ froiu them only by being more 
generalized. The normal resting muscle is, physiologically speaking, in a constant state 
of lonie contraction, and exhibits a certain reHex tone or tonus (muscle-tone) due to the 
combined action of two factors, one local and one nervous. Any muscular spasm, rigidity, 
or spasticity set up by increase of this normal tone within physiological limits, may properly 
be referred to as a condition of tonic contraction. But when a spasticity is pathological, 
as are all the " tonic contractions " of the clinician, it should no longer be referred to as a 
state of tonic contraction, especially as it corresponds satisfactorily with the physiological 
■ tetanic contraction " or " tetanus.' .V ty])ical pathological spasticity or active contrac- 
ture is seen in Sherrington's " decerebrate rigidity,' the extensor spasm observed in the 
limbs of the cat or rabbit after removal of the cerebral hemispheres and basal ganglia. This 
rigidity lasts for several days, and is due to the removal of the inhibitory impulses normally 
reaching the cord from the cortex and thalanuis. A similar rigidity, though, of course, 
with a (lilleriiit distribution, is seen in such disorders as hemi|)legia, cortical losses, lateral 
sclerosis. Kriedn ichs ataxia, subacute combined degeneration, and transverse lesions of the 
c<ird. 

The active contractures lollowing licmiiilegiii or cortical lesions in the motor area are 
confined to the affected side of the body, and should not be <lillicult to diagnose. Then- 
are three varieties of rigidity after hemiplegia, but only the last of these is usually described 
as a conlraelure : (1) Initial rigidity, present at the onset and lasting only for a few hours ; 
{'2) l'',arly rigidity, beginiiing within a lew days of the stroke and lasting for a week or a few 
weeks, posnibly due to tin- irritation of blood-clot at the site of the cerebral lesion : (!!) Late 
rigidity or contracture, first appearing several weeks or months after the .stroke, and due 
to the fact that while all the muscles of the affected limbs are spastic, certain groups of them 
arc stronger than their antagonists. Thus the thumb is flexed and pressed into the palm, 
the fingers clenched, the wrist and elbow flexed, the forciirm pronatcd, and the arm adducted. 
The thigh is a<ldu<led. the knee extended, and the heel drawn up, the fool inverted, and 
a charaelerislic spastic gait results. The deep reflexes arc increased on the liemiplegic side, 
where, loo, ankle-clomis and Itablnski's extensor reflex can be oblaincd. The lapse of 
years conxcrts these a(li\c eontractures into passive in conse(|Ucncc of the stnictural 
changes that take |il.iee in the muscles, f'ascia>, and joints. 

(dntraelures are highly characteristic' of con<ienilal and act/nireil cerebral iliple<iias or 
liiiiiijilegias line to cortical lesions, cortical sclerosis, or poreiicephalus (see CoN'ritAcrioNS. 
A rui'.roTic, p. l;tl). The patients show bilateral spastic paralysis; one side is sometimes 
affected more severely than t\u: other. If the legs only arc affected the condition is known 
as Tyittlc's disease, ami the gait is • cross-Ieggecl ' or * scissor,' the feel being pointed and 
iiiverli-d. aiul the thighs addiieteil. Kvpliosis is often seen, anil the arms, it iii\dl\i(l. arc 



140 CONTRACTURES 

lield in the position of a hemiplegic arm (see above). In the acquired cases the spastic 
paresis is oftener unilateral than bilateral ; the nutrition of the affected limb suffers con- 
spicuously, and its growth is retarded and incomplete. 

In Friedreich's disease, a familial disorder beginning usually between the ages of se\en 
and seventeen, and seen oftenest in males, characterized by ataxia, intention-tremor, 
nystagmus, and hesitating or syllabic speech, active contracture sets up scoliosis or scolio- 
kyphosis, pes varus or equinovarus, and ' main bote " — an analogous deformity of the 
hand with hyperextension of the terminal ])lialanges. These contractures are partly due 
to muscular atrophy, partly (in the case of the foot ) to over use of certain muscles in attempts 
at equilibration ; the heel is drawn up, the dorsum of the foot arched, the sole hollowed 
out. the toes flexed at the interphalangeal joints and hyperextended at the metatarso- 
l)halangeal ; prominent hypertrophy of the extensor longus hallucis has been found. 

In suhdcitte combined degenerfilioii. in which may be included lateral sclerosis if the 
degeneration mainly affects the upper motor neurons, there will be contractures. The 
earliest symptoms are connected with sensation ; but the patient, usually an ansemic adult 
inthe .second half of life, presently develops spasticity in his legs. The limbs tend to draw 
u|) as he lies in bed, from flexor spasm ; the gait becomes spastic, and walking is soon 
impossible — the condition becoming one of spastic paraplegia. The deep reflexes are 
increased, and Babinski's sign is present ; segmental areas of anaesthesia can be made out, 
and control over the spliincters is weakened. After some months, this spastic stage gives 
place to flaccidity. control over the sphincters is lost, and the patient rapidly runs down hill. 
In eases of transverse myelitis or transverse lesions of the cord, and in certain cases of hcemato- 
ini/clia of insidious onset, in which the haemorrhage perhaps takes place into an already 
dilated central canal, spasticity with increased deep reflexes, loss of sensation, and loss of 
ejjntrol over the sphincters is the rule. The diagnosis is facilitated by the fact that no 
symptoms occur in parts of the body innervated from above the cord lesion ; at the level 
of the' lesion there is evidence of nerve-irritation (girdle pain, hypera-sthesia). In these 
cases the flexors of the leg overpower the extensors ; the limbs draw themselves up again, 
sooner or later, as often as they are extended for the patient. 

So far. the active contractures considered have all been due to lesions of the U|)per 
motor neuron. A second class contains those resulting from lesions of the lower motor 
neuron and the subsequent muscular atrophy. These contractures arise either from the 
unbalanced action of the muscles that normally antagonize those that have atrophied, or 
from late shrinkage of the paralyzed muscles themselves; and a spinal curvature may 
come on from the adoption of some posture that facilitates locomotion or the occupations 
of life when the spinal nuiscles are intact. Acute and chronic poliomyelitis, neuritis, and 
lesions of the ner^•(^s liave to be discussed in this connection. Acute ])olionii/elitis. or infantile 
paralysis, begins suddenly with malaise, pains, and an acute febrile attack ; the flaccid 
paralysis appears early, and contractures begin to show themselves within a few months, 
as a rule. The limbs are most involved, isolated muscles or groups of muscles being 
paralyzed ; and it should be noted that the jjaralysis is distributed in accordance with the 
nuclear grouping of the muscles in the anterior cornual regions of the cord. Sensation is 
affected only in the rarest instances. If many muscles in a limb are paralyzed, its growth is 
nuich impaired. Contractures are common in chronic poliomijelitis and the various forms of 
progressive m.uscular atrophy of neuropathic origin (see Contraction.s, Fibrillar, p. 134). the 
hands and feet being mainly involved, with the production of various forms of club-foot and 
claw-hand. All the muscles are involved together, and there is no selection of certain 
groujis for paralysis as is the case in acute poliomyelitis. In addition, fibrillar contractions 
can be seen in the degenerating muscles, provided that they are not covered too thickly 
with subcutaneous tissue. The onset is insidious, and the disease occurs most often in 
middle age ; the commonest type is that in which the hands are first and most involved, 
but in other cases the legs, and in others the upper arm and shoulder, first give evidence 
of the disease. Contractures are seen occasionally in alcoholic neuritis of the motor type, 
and more frequently in arseniccd neuritis, talipes equinovarus or flexor contracture of the 
wrist, with excessive muscular hyperaesthesia, being noted ; such deformities are rare in 
other forms of neuritis, such as those due to lead, diabetes, influenza, diphtheria, etc. 
Secondary contracture of the muscles on the affected side in Bell's facial paralysis may 
occur, and gives rise to the impression that the soimd side of the face is paralyzed while the 



COXTRAt'TL'RES 



141 



face is at rest, lor the face as a whole is jjulU'd o\er to tlie affected side {Fig. 198, p. 492): 
on vohmtary movement, however, the healthy side will be found to move normally, while 
the jjaralyzed side remains comparatively still. Contractures usually follow severe injury 
of nerves. luiless satisfactory healing of the wound and regeneration of the nerve-trunk.s 
take ])lace. 

.Ictirc CDiilritrtiires from disuse may occur in otherwise healthy subjects who for any 
reason may have been kept too long- in one position. Patients who have lain on their backs 
in bed lor long periods may have a temporary tali))es e(piinus when they get up — an active 
contracture due to the weight of the bedclothes resting on the toes and keeping the feet 
extended. Fractured or injured limbs that have been splinted and kept too long in one 
position, often exhibit active contractures when the 
splints are removed (e.g., Volkmann's ischa-mic contrac- 
ture of the forearm. Fig. 38). In some cases the con- 
tracture is due to fixation of the muscles, tendons, or 
muscle-sheaths by inflammatory products that have 
become organized, in others to adhesions or bony de- 
posits that have formed themselves in or about the 
joints, while in others mere disuse, without inflamniatory 
changes, may \mdcrlic these contractures : all of these 
would be avdideil by the timely use of massage and 
movement. 

Paralyses occur in perhaps 25 per cent of all 
patients with lifisleriii. in two main types : the laiei- 
flaccid, the commoner spastic, and often marked enough 
to |)roduce active contracture. In hysterical contracture 
the affected muscles are not wasted exce])t in severe 
cases of long duration : the deep reflexes are increase<l : 
ankle-clonus may be ])resent ; but Babinski's sign is 
jjrobably lu-vcr observed. The limbs are most affected 
(hemi. mono-, or para|)lcgia), less often the muscles of 
the face, eyelids, lips, or t(mgue. Certain attilu<les are 
highly characteristic of hysterical spastic paralyses : 
the elbows, wrists, and lingers are ke])t Hexed, the arms 
are adducted : llic hip muiI knee are extended, and the 
foot is held in a |i(isilion of talipes C(|uinovarus : ptosis 
may be seen, from spasm of the orbieidaris ; torticollis 
from contracture of the sicrnomastoid. In the less seven' 
eases the stillness ami paresis are neilher complele nor 
marked enoMi:li Im- I lie condition to be relVrred to as a 
contracture. In all irislaiu-cs the deformity produced is 
tlie result of :irli\c rrniscular spasm, aiul in severe cases 
it camuit be ov rrcoinc b\ cNereisc of I he p.ilicni's will. 



gahani/aliAu. or by ll 
'I'he colli raclur 
abolislie.l only by d 
guisliiiig hyslerieal 



ten I 



ml 



pplicalioii of mechani 
rsisis during sleep 
isllicsia a cliarMcIc 
rhiies from lliosc 



ll force, 
and is 
disliii- 

dile lo 




establish permaiieiil passive < 
contrMcliire is the palieiil's ii- 
tion ,,r llie deformily exiiiiiih 
the liircps. the triceps can Ik 
is made lo Ilex llic :iriii liirlhi 



inths. or e\en years : and in 
[•lianges about the joints may 



<)r<;aiiie disease Hyslerieal coiil i:i<'l iiies oflcn lasl Tor i 
cases of long slandiiig muscular atrophy and slruclura 

finlracture from disuse. Highly characteristic of hysterical 
• of antagonislic muscles lo pievc'iit passive or active correc- 
I. If. for example, the arm is semillexed by contracture of 
Icll lo eoiilrael and resist the movemeiil when IIk' allempt 
r. A siiiiil:ir eoni nicl :oii of Mic I lieeps can lie IVIl cir seen if 
the palieni is asked lo bend llie jniiil lieisclf : uilli llic rcsiill lli.il llii' joiiil leniains un- 
moved, alllioiigli all signs of great cllorl lo bcnil llic arm may be displayed. I'aiii and 
tendciness in the conlractcd muscles are usual : and oilier h\slerical sligmala such as 
hcmiameslliesia. pariesi licsia. claviis or globus liyslcricns, and llic hyslerieal lempcrauicnl 
l,'<ncrall\, will iiol be wanliiii;. Spcci.il loriiis of liysliiic.il coiilraclurc iiia>- give rise lo 



142 



CONTRACTURES 




-Dupuytren's Contracture. 



great trouble in diagnosis by imitating definite conditions or diseases. Tlius a painful 
' hysterical hip " or • hysterical knee ' may pass on from surgeon to surgeon, imtil one is 
found to operate upon the normal joint for tuberculous arthritis ; hysterical spasm of 
some of the abdominal muscles may lead to the diagnosis of jjregnancy or new growth — 
pseudo-cyesis or phantom tumour ; hysterical contracture of muscles in the neck or 

shoulder may be diagnosed as 
new Lirowth. the palpable tumour 
\ anishing only when the patient 
has been ansesthetized and is on 
the operating - table awaiting 
incision. 

TiirticiilUs. or wryneck, in 
adults, may be regarded as a 
functional disease, and is a form 
of tic. characterized in its later 
stages by contracture of the 
affected muscles of the neck. 
The muscles chiefly affected are 
those supplied by the spinal 
accessory nerve. Its clonic 

variety is easy to diagnose ; but 
wliere the spasms are tetanic (or 
tonic) rather than clonic, the 
diagnosis must be made from 
such conditions as cervical 
caries, rheumatic myositis, or 
deep inflammation in the glands 
of the neck. Congenital torticollis dates from birth, usually affects the right sterno- 
mastoid muscle, and is often associated with facial asymmetry — when it is perhaps due 
to congenital defect of the centres in the bulb. The face is smaller on the side of the 
affected sternomastoid. Congenital torticollis is distinguished from the form of wryneck 
produced in infants by rupture of the sternomastoid muscle at birth during delivery, by 
the fact that in the latter a callus is to be felt at the site of tlie rupture. 

Passive Contractures are those 
due to affections of the bones, joints 
or soft tissues, that mechanically 
obstruct correction of the deformities 
they produce. They also result from 
long continuance of the active contrac- 
tures considered above, by a gradual 
process of transition. The contracted 
limbs can only be straightened by 
surgical measures, or by manipulations 
severe enough to rupture the ob- 
structions. 

Passive contractures may result 
from the most varied local organic 
diseases of the affected parts. 
Dupuytren's Contracture of the jjalmar 
fascia, leading to deformity of the 
little and ring fingers {Fig. 59) is so 
characteristic that it can seldom be 
mistaken. It is prone to occur in 

gouty subjects and in those who use the palms of their hands most, as in the case of 
coachmen and those who use spades, etc. In diseases of the joints, such as rheimiatisni, 
rheumatoid arthritis, spondylitis deformans, tuberculosis, gonorrhoea, etc., the patient 
may lie in bed or go about for weeks or months in some bent or contorted position that 
involves the minimum of discomfort ; ankylosis of the affected joints often results from 







-c^ 




^.— Cicatricial contrac 
Rutherford Morisou'c 



are after a burn. 
Jiilroductvm to Surffenj.) 



CONVULSIONS 143 

the growth of adhesions, eechondroses, or exostoses in and about the edges of the joints, 
that permanently hniit their range of movement. Corresponding shortening will take place 
in the muscles that are relaxed, and a passive contracture results. The growth of a tumour 
in or about a joint may produce identical results. Traumatic or inflanunatory lesions about 
the muscles or their tendons may establish inflammatory products locally that permanently 
limit the movements of these structures. Large superficial scars due to extensive burns 
or losses of skin and the superficial tissues, being, composed mainly of fibrous tissue, may 
contract, and so bring about marked contractures (see Fig. 60). 

Spondi/litis defnrinaiis. a chronic malady of the spinal colunm (p. (i48) often results in 
contractures and partial ossification of the ligaments and muscles of the back ; and extreme 
deformity may arise from myositis ossificans, a rare but easily, diagnosed affection in which 
the muscles all over the body gradually become rigid from calcification : the patient has 
generally been normal up to adult life, and then becomes the subject of acute attacks of 
pain in various muscles, accomiianied by local myositic .swelling and some pyrexia : after 
the local inflammation subsides, calcium salts are deposited in the site that has been inflamed 
and the affected muscle becomes stiff and hard. Weeks or months may elapse between 
successive attacks of tljiis kind, but the number of calcified muscles slowly mounts up. 
until in extreme instances the jjatient is rigid almost from head to foot — the • ossified man.' 

The diagnosis of the cause of a passive contracture will obviously de])end upon the 
results of the physical examination of the affected part, and upon the success with which 
a true history of the onset and course of the case can be elicited. A. J. Jex-Blalic. 

CONVULSIONS, or CONVULSIVE SEIZURES, are paroxysms of involuntary 
muscular contractions. They may be divided into two classes, according as they are local 
or general : local convulsions lia\e been considered under the heading Conth.vctions. 
SpASJroDic (p. VMi). and the following account deals mainly with general convulsions. The 
general convulsions without loss of consciou^HCss that constitute RiGOifh are described under 
that heading (p. .594) ; with this exception, general convulsions are almost always accom- 
panied by loss of consciousness, excepting in some few cases of partial epilepsy and of 
hysteria. 

In most cases of convulsions, both sides of the body — face, neck, arms, trunk, and legs — 
are convulsed equally. But it sometimes happens that though their cause is apparently 
general, the movements are unilateral, or much more marked on one side of the body than 
the other ; for present purposes such convulsions may still be termed general. I'sually 
convulsions arc clonic, less often tetanic or t<mic. 

■ Fits ' may be defined roughly as any sudden jjuroxysms or seizures occurring in the 
course of any disease. In eomnKin usage, lutwever. a " fit " is a convulsive fit. or fit of 
convulsions, and if umiualilied, the term usually means an epileptic fit, but not always. 

Certain clinical features are common to aJuHisI all conxulsive seizures in which 
consciousness is lost. If the onset is sud<len. as it usualh is, I he patient is apt to fall dow?i 
and injure himself miless already recumbent. If the nniseles of the mouth and jaws are 
involved and saliva is secreted freely, the mouth foams ; if the tongue or cheeks are bitten, 
the foam bci'omes stained with blood. Clenching of the jaws will niaki- the breathing 
laboured stertorous, and inclTectual. If the nuiscles of respiration arc greatly affected, 
cyanosis, with congestion of the face, neck, and exposed parts, will be observed. The 
convulsive movcmenis ar<' typically clonic, limited in range. ])urposeless, and accon\i)anie(l 
by more or less rigidity. If the rigidity is marked, the amplitude of the movements will 
be reduced correspondingly, so that the condition may even become one of sliffiu-ss and 
tetanic (<ir so-called Ionic) spasm. It is eliaractcrisi ic of epilepsy that the lil sliouM consist 
of a brief tetanic stage followed by a longer stage ofc-lonus ; but convulsive attacks of e\ei\ 
sort may occur in epilepsy, and cither the tetanic or the clonic stage nuiy be ab.sent or so 
brief as to pass unnoticed. Control over the organic reflexes of micturition and defa-cation 
is often lost, the bladder and rectum being emptied involuntarily. -\s a rule the reflexes 
cannot be oblaiiied while the convulsions last, and are lost or diminished for some hours 
after they are over, or arc uuc<|ual on the two sides of the body. When the lit is over and 
the patients have recovered consciousness, they often complain of headache and lassitude, 
showing diminished scnsibilily to all impressions, menial hebetude, and great sleepiness. 
Less orien. Ilic palieni becomes exeileil or lenilicd allci- a lil, or cNcii maniacMl. ami he may 



114 



CONVULSIONS 



also exhibit autoiiuitism lor lioiirs or even days ; in none of these conditions will he be 
responsible for his actions. The duration of general convulsions is commonly to be measured 
in seconds or minutes ; but in severe cases they may go on for hours if untreated, and in the 
status epilepticus may last for days with only brief intermissions. Prolonged convulsions 
due to any cause may raise the temperature several degrees ; when they are iniilateral, 
the temperature is raised more on the affected side tlian on the other. Albuminuria after 
a fit is very common, and may last for a day or two ; it is by no means necessarily evidence 
that the fit was uriemic. 

The morbid conditions in which local or partial convulsions, and in rarer instances general 
convulsions also, occur without loss of consciousness, have been considered under Contrac- 
tions, Spasmodic (p. 136), but for the sake of clearness may be recapitulated : — 



Fat iguc 

Nc'ivous cxliaustion 

Hiibit spasm 

Spasmodic tic 

Myoclonus 



Hysteria 

Jacksonian e])ilei)sy 
Chorea electrica (Henncli) 
Tetany 



Tetanus 
Hydrophobia 
Strychnine poisoning 
Malingering. 



The convulsions commonly accompanied by loss of consciousness will be considered 
here under the following heads : — 

1. General Convulsions of Infants and Children, seen in : — 

.Mriiiiiiiitis Idiocy 



Hereditaiy sypliilis 
Congenital heart disease 
Ccrci)ral paralysis 
Onset <il' acute fevers 



Drug poisoning 
Enlarged thymus 



Rickets 

Epilepsy, minor and major. 



2. General Convulsions of Adolescents and Adults, seen in : — 

Intracranial growth 
General paralysis 
Chronic alcoholism 
Cerebral syphilis 
Hysteria 



Ejiilepsy, minor and nuijor. 
Jacksonian epile])sy 
E])ileptiforni convulsions — 

Uremia 

Pregnancy 

Seyeiv heart disease 



.Vspliyxia 

Stokcs-.Xdams" disease 
Saturnine encephalopathy 
Cerebral lesions : — 
."Vpoijlexy 



Meningitis 



3. Unilateral Convulsions, seen in 



Ai>oplcxy 

Intracranial growth 



Meningitis 
Epilepsy, majc 



and minor 



Malingering. 



.Jacksonian epilepsy 
Disseminated sclerosis. 



General Convulsions of Infants and Children. — Among the commonest of all con- 
\ ulsive seizures are those occurring in children of tender age, known as infantile convulsions. 
The sexes are affected equally ; about a third of the cases take place during the first year 
of life, two-thirds during the first two years ; and they are rare, apart from epilepsy, after 
the age of five or six. They arc of more serious import in infants under six months than in 
older children, and also in anaemic and weakly infants. In hcrcdildri/ .ti/jihilis convulsions 
often prove fatal during the first week of life. For the rest, in about half the patients rickets 
is the predisposing cause : in many of the others some local irritation, such as inflammation 
of the gimis in dentition, diseases of the nose or ears, the presence of irritating food or tt'orw.v 
in the intestine, renal or vesical calculus, or phimosis, can be found : while convulsions at 
(he onset of acute infectious diseases, such as scarlet fever, |>neunionia, measles, whooping- 
cough, or during their cour.se. and in nephritis, are not infreiiuent. Overdosing with drugs 
— strychnine, atropine, santonin, morphia — or with alcohol, may bring on convulsions. 
FViglit and over-strung emotions are included among the causes of infantile convulsions ; 
how far inheritance, the neurotic or neiu'opathic taint, is responsible for them is uncertain. 
They occur in children with enlargement of the thymus gland, the so-called status lymphaticus. 
and in these not infrequently a fit has a fatal issue. Finally, it must be remembered that 
in any child there may be early evidence of epilepsy, or of organic disease of the brain. Their 
diagnosis demands a very careful examination of the child, and also of its diet and the 
hygiene of its daily life. They may be due to congenital heart disease, when there will be 
enlargement of the heart, a cardiac murinur or murmurs, and some degree of cyanosis. In 
children with organic disease of the brain (poreucephalus. congenital or actpiired cerebral 
paralf/sis. sjxislic paraplegia, etc.) there will be paralysis, spasm, and muscidar atrophy, and 
l)ri>l)ably mental defect. If the convulsions are due to the onset of some acute infectious 
disorder, they will come on suddenly in a child previously well, and will be accom|ianied by 



CONVULSIONS 145 

high fever and followed by the characteristic rash. Similar convulsions and fever may 
occur in mciihigitis. usually towards the end of the diseas^; Tliey are not rare in ivhooping- 
coiigh, particularly in rachitic infants, being precipitated by the asphyxia resulting from 
the whooping, and not rarely causing death. The diagnosis of fits due to drugs or alcohol, 
taken either by the child, or by the mother if the child is being suckled, will dei)en(i upon 
obtaining an adequate history of the ease. In what way eiiliirgcniciil of the llii/iiiiin brings 
about convulsions is not known ; the condition is fortunately rare, and is hardly ever 
diagnosed during life. The ftts occurring in hi/ilrorrphaliis and the various degrees of mental 
defect need only be mentioned. 

It is to rickets that one nuist look for the explanation of most convulsions occurring 
between the ages of three months and four or five years. The nervous system is unstable 
in all young children, the power of cerebral inhibition not being acquired for several years. 
In rickets this instability is much increased, and finds expression in irritability, tits of 
screaming, restlessness, inability to sleep well at night, and in the more serious troubles of 
tetany, laryngismus stridulus, and convulsions. Any child with fits should be scrutinized 
for evidence of rickets — exaggerated curvatures in the long bones, the rickety rosary, a 
Harrison's sulcus on the sides of the chest, the large and bulging rickety head, thinness of 
tlie hair on the Irack of the head (due to head-rolling), a tumid and Uaecid abdomen, lateness 
in the closure of the anterior fontanelle, and general muscular debility. Enquiry should be 
made for other symptoms common in rickets that will come under the observation of the 
mother or nurse — tenderness of the bones and skull on handling and washing, head-rolling 
due to tenderness of the skull, nnich sweating about the head in sleep, broken slumber, 
proneness to gastro-intestinal upsets, eonsti])ation and mucous stools or constipation 
alternating with diarrhoa. unusual liability to coryza and bronchitis (or " catching cold "). 
The feeding and hygiene of the child must be gone into : in low life, rickets is mainly due to 
deficiency of fat and protein in the diet, with excess of carbohydrate food, whereas in high 
life the diet is more likely to err by lack of freshness due to too careful sterilization or to the 
use of patent foods ; rickety children all suffer from want of enough exposure to fresh air 
and sunshine. Hut if rickets is the main predisposing cause of infantile convulsions, it must 
be remembered that they arc actually Ijrouglit on by some secondary exciting cause, such 
as a gastro-intestinal disturbance with diarrhaa or vomiting, or reflex irritation of any sort. 
Whether dentition is in itself enough to account for convulsions is extremely doubtful, 
although that " teething-fits ' do occur is one of the things that every woman knows. 

KpilejiS!/ is one of the last causes of infantile convulsions that should be thought of, 
cxeepl when the fits occur for the first time in tolerably healthy children more than three 
or four years old. .\ bad family history of fits or of insanity would make ci)ilcpsy more 
probable ; so would the occurrence of an aiini before the fit, and the division of the fit into 
a Ionic and a clonic stage, with biting of the tongue or checks. The repetition of fits for 
which there is no local or general cause, such as those described above, would be in favour of 
<|iilepsy, particularly if the sc(|ueiice extended over a long period of time. But one fit 
undoubtedly facilitates the occurrence of another soon afterwards, so that the recurrence 
of convulsions for a few ihi\s or weeks in a rickety child is not enough to justify the 
diagnosis ^)r epilipsy. 

General Convulsions of Adolescents and Adults. — Th<' convulsions of eiiilepsi/, 
iri<lu(liiig bolli Ihc iiKijor and Die minor forms, are very variable In extent and <luralion. 
In the minor degrees, ov petit nial. there is usually brief tonic or tetanic spasm, with loss of 
eonseiousness, but without clonus or convulsions. In severer eases this is known as tetainiid 
cjiilrpsi/, a tetanic spasm convulsing the patient lor some seconds, or <'ven for a minute oi- 
two. with great risk of dealh by asphyxia. In partiid epilepsij the con\iilsions arc conlined 
to part of the body — the face, perhaps, or the arms and face. Midway belween minor and 
major epilepsy (iowers places " epilepsia media, in which there is nniscular spasm of tonic 
character, withont the clonic spasm which follows when the tonic spasm is more severe." 
In major epilepsij the typical jjieliirc is as follows : after experiencing an aiua or warning of 
sonic sort lor a lew seconds, the |)alienl is seized with a general lelanic spasm, cries out, and 
falls to the ground, this tetanic or tonic stagi' lasting for from fi\c to thirty seconds. This 
tlicn gives place to the clonic stage, or convulsions, with foaming at the mouth, and clonic 
jiictilations that are often mic(|ual on the two sides of the body, .\flcr a few miimtes the 
<lc>iHis dies away and the patient is left eoiiialosc or stupelied, with a headache that is slept 



146 CONVULSION'S 

off in the course of the next few hours. Consciousness is always lost in true epilepsy ; the 
extent and duration of the convulsions, however, are highly variable. The fits of Jacksonian 
epilepsy are rarely generalized ; the condition is considered below. In true e])ilepsy there 
is no known organic lesion of the brain ; the loss of consciousness and the convulsions are due 
to some unknown functional disturbance of its action : but up|)arently identical fits may 
occur in the course of a number of diseases in whicli organic lesions are present either in the 
brain or elsewhere, and to these the name epileptiform coiiriilsions is given. They are seen 
most often in unemia. in which the kidneys are severely diseased and toxsemia results ; the 
patient exhibits the characteristic picture of advanced renal disease, with headache, high 
blood-pressure, hypertrophied heart, albinninuria, probably retinal changes, and anaemia ; 
or may have a stricture of the urethra or an enlarged prostate with secondary ascending 
nephritis ; or may be the subject of renal tuberculosis perhaijs. It must not be forgotten 
that transient albuminuria is commonly present after fits due to any cause whatever. In 
the intervals between uraemic convulsions the patient may remain unconscious. 

The convulsions occurring in connection with pregnaney are known as eclamplic fits. 
the condition as eclampsia. The majority of such convulsions come on before labour, some 
during labour, and 15 or 20 per cent during the first week after jiarturition : any fits occurring 
after this are ])robably due to some cause — ura-mia. for exam])Ie — other than pregnancy or 
jKirturition. In many cases the fits occur suddenly and without any warning, or after no 
more than a brief period of lieadache or restlessness, or after vomiting. Eclampsia appears 
to be an auto-intoxication accompanied by a profound disturbance of the protein 
metabolism ; its primary cause is in the placenta. Its diagnosis can rarely be difficult. 
There is nearly always albuminuria, and some observers regard puerperal eclampsia as one 
variety of uraemia. 

E]iile])tiform convulsions may occur in severe heart or lung disease, and, indeed, in the 
terminal stages of many disorders, due in part to asphyxia, in part to toxaemia. Like 
certain obstinate infantile convulsions, they may often be stoi)ped by the administration 
of oxygen. 

In Stokes-Adams' disease (]>. 83), epileptiform or apoplectiform cf)nvulsive seizures 
occur from time to time, no doubt due to the asphyxia and cerebral ana'mia resulting from 
temporary cessation of the heart's action. The radial pulse is habitually slow in this 
disorder, but becomes suddenly slower at the time of the ' attacks,' beating jjerhaps forty 
or thirty or even only twenty times to the minute ; the cardiac auricles, on the other hand, 
beat at the normal rate. The patients are usually arteriosclerotic people in the second 
half of life ; if they are seen in their convulsions, the diagnosis of apoplexy will ))robably 
be made, only to be corrected later when it is found that the attack leaves no ))aralysis or 
paresis behind it, that similar seizures have occurred before, and that the pulse becomes 
excessively slow during the seizures. 

General convulsions due to direct irritation or disease of the brain may occur in a 
large number of cerebral lesions, unilateral or bilateral, most commonly in the latter. In 
most of these there will be other signs or symptoms of disease, especially optic neuritis, 
that should suffice to clear up the diagnosis. Such convulsions may be seen in meningeal, 
subdural, or arachnoid hcemorrhage ; in meningitis due to the B. tuberculosis, Weichsell^aum's 
meningococcus, or other microbes : in eerebritis ; in congenital anomalies of the brain such as 
porericephalus, hydrocephalus, and the abnormalities met with in idiots and mentally defective 
children generally ; and in cerebral or cerebellar abscess, tumour, or aneurysm, when sufficient 
growtli has taken place to raise the intracranial pressure generally. In another group may 
be placed those cases in which extensive degenerative changes have taken place in the brain ; 
fits are common in the second and third stages oi general parcdysis of the insane, when other 
signs, such as defective memory and judgement, grandiose ideas, inequality or reflex im- 
mobility of the pupils, blurred speech, tremors of the tongue and face, loss or exaggeration 
of the deep reflexes, and nniscular weakness may be looked for : in the insanity of chronic 
alcoholism, with its tremors and inco-ordination, its marked sensory perversions, and its 
paramnesia or illusions of memory ; and in cerebral syphilis, where the lesions may be either 
vascular, gummatous, meningeal, diffuse, or a combination of any or all of these, and the 
main symptoms are headache, insomnia, attacks of aphasia and hemiplegic or epileptiform 
convulsions, paralysis of cranial nerves, and in addition dementia in the diffuse cases. 
Chronic plumbism may produce cerebral symptoms of the most varied kind (saturnine 



CONVULSIONS 147 

cuccplialopalh}/). from simple headache to acute mania, and amongst the phenomena, 
convulsions of epileptiform type may be prominent. The diagnosis is based upon the 
iiistory, the occupation, the other symptoms of lead jjoisoning (p. 34). and ])crhaps upon 
the discovery of lead salts in the urine. 

Lastly must be mentioned the general convulsions of the hysterical and of malingerers. 
In lij/sleria. the fits are noisy and protracted performances, the movements more or less 
purposive and (]uite unlike clonus ; the patient becomes red in the face rather than blue 
or white ; consciousness is not lost, attempts to open the eyes are resisted, pressure into 
the supra-orbital notch causes withdrawal of the head, the sufferer's hand is withdrawn 
if pressure is made between a nail and its matrix ; the sphincters are not relaxed, and the 
tongue or cheeks are rarely bitten. The convulsions are brought on by some emotional 
upset, and tend to cease when unsympathetically received. The malingerer may display no 
little art and skill in his convulsions, which are modelled on those of epilepsy ; here again 
the sufferer is red in the face rather than blue, although he may breathe stertorously, and, 
with the help of a little soap, foam at the mouth ; consciousness is not lost, the corneal reflex 
is present, the head and hand are withdrawn from ])ainful impressions ; the sphincters are 
not relaxed : perspiration is usual : it is said that in epilepsy, if the hands are clenched, the 
thumb is buried in the palm, whereas the malingerer clenches it outside the fingers ; on the 
detection of its character, the simulated fit ends as suddenly as it began. 

Unilateral Convulsions. — The convidsions in apoplexy are habitually limited to one 
side of the body. The onset of apoplexy, more often gradual than sudden, is generally 
preceded by headache, dizziness, and tingling or weakness in some part of the body ; and 
it is more marked in cerebral hajmorrhage than in embolism or thrombosis. The loss of 
consciousness comes on earlier and persists longer in cerebral haemorrhage than in the other 
two conditions. When the convulsions are prominent the case is described as one of epilepti- 
form (ipople.cij. Cerebral Itcemorrhage is commoner in middle-life, in persons with high 
blood-pressure and hypertrophied hearts, and in the subjects of arteriosclerosis ; cerebral 
embolism is associated with endocarditis or intracardiac thrombosis, and occurs oftenest 
in young patients with heart-disease ; eerebrnl thrombonis is seen in syphilitic patients, and 
in those with vascular disease, and is characteristically of slow onset after premonitory 
warnings. 

In cerebral abscess and cerebral tumour convulsions are not very common, and usually 
appear only after the diagnosis has been made clear by the occurrence of such cardinal 
symptoms as headache, vomiting on change of position, optic neuritis (choked disc), and 
localizing signs pointing to intracranial tumour : but it may happen that an epileptiform 
fit with unilateral or bilateral convulsions is the first sign that anything is wrong, or at any 
rate the lirsl thing that makes the |)atient consult a medical man. The headaelie that 
follows a coiuulsivc seizure is likely to be very severe and prolonged. Of the two. cerebral 
abscess is the more likely in patients with chronic suppurative disease of the ear or nose, or 
of the facial and frontal sinuses. Meningitis — especially tuberculous meningitis in its later 
stages — often exhibits imilateral or bilateral convulsions, si(uint and other local ))aralyses, 
more or less coma or mental apathy, gastro-intestinal symptoms. t'heync-Stokes breath- 
ing, and irregularity of the ])ulse-rate and temperature : lumbar puncture and examination 
of the eerebrdspiiial lluid (|). :H)i} may be ie(iuire(l in establisliiiig the diagnosis and in 
<listinguishing between thi tuberculous, the suppurative and t h<' cpidemie < irchrospinal — 
■ spotted fever ' — forms. 

The unilateral convulsions of Jacksduian epilcpsif are rarely dillieull to diagnose. The 
patient usually gives a history of head injury, and often a cranial sear or irregularity is to 
be found. There is no loss of consciousness during the attack, except in very severe 
and inveterate cases ; usually only one limb is involved, and an aura of some sort usually 
piccedes the convulsions, which exhibit a characteristic "spread' — beginning in a single 
muscle or group of muscles, and spreading thence to the muscles whose cortical areas ol 
representation adjoin that of (he nniscic hrst involved. In .lacksonian epilepsy there is 
almost always an irritative lesion of the motor cortex or its immediate vicinity, due to 
trainna. syphilitic meningitis, or new growth ; ])aresis or ])aralysis of the affected muscles 
follows the convulsions, and in the course of time becomes marked. The " spread ' 
is fre(|ueiitly characteristic; if the face is involved first, the arm follows, and then the 
leg : 11 the iiand is attacked first, the eonvuisiiins spread up the aim, llicn lo the lace, last 



148 CONVULSIONS 

to the leg. In tlie severer cases, where the whole side of tlie iiatient is convulsed, con- 
sciousness is lost, and then the convulsions may become bilateral. 

Unilateral convulsions do not occur often in epilepsy or infnnlile convulsions, or epilepti- 
form convulsions, and when they do there is a danger lest the diagnasis of apoplexy or some 
focal organic lesion of the brain be made. There is nothing in the character or distribution 
of the convulsions in these cases to enable a diagnosis to be made, and it is only after they 
are over, and it is found that no evidence of organic cerebral mischief is left behind, that 
their functional nature can be established. They are not followed by any permanent 
paresis, paralysis, or atrophy of the muscles on the affected side. It must be remembered 
that unilateral convulsions, the so-called " apoplectiform ' convulsions, may occur excep- 
tionally in some of the conditions detailed under Grou|) 2. 

In disseminated sclerosis, hemi]3legic apoplectiform attacks like those seen in general 
|)aralysis are not rare, often accompanied by aphasia. These attacks are both transient and 
recurrent. The patients are likely to exhibit other evidences of disseminated sclerosis — 
a childish and optimistic mental attitude, optic atrophy, nystagmus, impaired articulation, 
intention tremor, undue muscular fatigability ; the deep reflexes are commonly increased. 
Babinski's extensor plantar reflex is present, sensation is but little affected, and control 
over the sphincters is rarely lost until late in the disease, .1. J. Jex-BIahc 

CORNEA, ULCERATION OF.— (See Ulceration of the Cornea, p. 733,) 

CORYZA.— (See DisciiAUGE, Nasal, p. 178.) 

COUGH. — Cough is a signal that something is irritating a brandi of the vagus nerve 
or the cough centre, and is, in fact, nature's effort — often ill directed — to remove that 
something. Hence, to diagnose the cause of a cough it is necessary to know the branches 
of the vagus ; they are as follows : — 

(1) A small meningeal branch, of no interest as causing cough, though it may possibly 
account lor vomiting in meningitis ; (2) Arnold's branch to the ear — a cause of cough, 
though a rare one, due to affections (wax, eczema, etc.) of the external ear ; (3) Pharyngeal 
branch — a frequent source. of cough : (4) Superior laryngeal branch — sensory to base of 
tongue, larynx, etc., the most frequent source of cough, with or without visible changes : 
(.5) Inferior laryngeal branch — motor for action of coughing, not a cause of cough, but of 
inefficiency and other peculiarities in the act of coughing : (6) Cardiac branches — indirect 
causes through circulatory failure ; (7) Pulmonary branches — concerned in the cough of 
gross pulmonary or pleural disease ; (8) and (9) CEsophageal and jjericardial branches — 
possible but most rare causes : (10) Gastric branches — occasionally dyspepsia causes a 
cough. 

The irritants to which the .surfaces of the distribution of these nerves are exposed may 
be classified into : (1) Foreign bodies, e,g., dust, food, tobacco smoke, etc. ; (2) Excess 
of natural secretion ; (3) Pressure and inflammation : (4) Acute or chronic simple debility 
or increased irritability, e.g., after influenza, etc. 

In dealing with the treatment, there is no better division of coughs than into those 
which are helpful and those which are not, and the same division is most useful in arriving 
at a diagnosis of the cause of a cough, for if the cough succeeds in its object — the removal 
of the offending material — we can see, or at least enquire about, its nature, and this wiH 
at once give a strong clue to the locality of the irritable point, and very possibly also to 
the morbid process going on. Hence the first questions to ask a patient with a cough are : 
'• Do you bring anything uj) '? " '■ What do you bring up '? " 

Cough without Expectoration. — If the answer to the flr.st question be, " No. the 
cough is just a troublesome dry cough, witli no expectoration at all," we at once begin to 
think of the purely reflex coughs produced by an irritant which the cough itself is powerless 
to remove, and though we may often make a short cut to a diagnosis by other means of 
investigation, or observation of the general condition, the following routine should be 
followed if no prominent clue oflers itself : — 

1. Examine the external ear for wax, eczema, etc., although this is a comparatively 
rare cause of cough, excejjt in the si)ecial experience of aurists. 

2. Enquire whether any ordinary irritant, such as tobacco smoke, etc., brings it on ; 
this, of course, at once raises the suspicion that the nasopharynx or larynx is unduly 



COUGH 



149 



sensitive, and should lead to a careful examination of the region, whereupon a cause may 
be detected at once, such as chronic inflammation of any sort, or a long pendulous uvida, 
somewhat oedematous, or showing other signs of acute inflammation. Conditions of imdue 
irritability without anything to see occur after influenza or whooping-cough, and indeed 
remain long after the acute trouble has passed away from the regions : therefore enquiry 
must be made for some such illness. Such a cough is often seen when convalescents go 
into a cold bedroom, or get into cold sheets at night. 

8. .Ask the patient to cough voluntarily : the curious barking or rough cough of 
laryngitis and of pressure on the trachea from aneurysm or growth, also tlic very striking 
oough of jmralysis of the vocal cords, at once betray themselves ; there is no mistaking 
them when they have been once or twice heard in a hospital ward ; the same remark applies 
to the cough of whoo])ing-eough. 

4. l^xaiiiiiic the chest carefully for heart disease or early phthisis : the cough of both 
these conditions is commonly dry ; so too is the cough of the early hours of an oncoming 
hvonehitis or ])neumonia, but these can scarcely 
f;iil to give other indications. Children often 
suffer from very troublesome dry cough, some- 
times ])ersisting for months, as the result of 
reflex irritation from caseous or inflamed bron- 
chial glands ; the latter may be impossible of 
diagnosis from ])hysical signs, but they can 
often be seen verv elearlv with the ,r-ravs 
(F/e. (il). 

.■). If no cause reveals itself by now, the 
sliimaeli nuist be thought of. and its functional 
and physical conditions enejuired into and 
examined, and only after negative results from 
all these cnfpiiries and })rocedures may we think 
of a siiii|>le hysterical cough. 

Cough with Expectoration. — Expectoratimi 
generally makes the task of diagnosis nuieh 
easier, and from the simple insi)eetion of a 
spittoon il is frcfpiently possible to make an 
alniiisl eiiMiplcIc diagnosis of a case : the xcry 
stiik\ sputum of any acute inflanunalion in its 
early stages, tlic rusty sputum of pueunioniM. 
the stink of abscess or gangrene of the lung ami 
of liniiiehieetasis. the numnuihilion of ]jhthisieal 
spiila. the lidlhy s|iutuiii iif liicjiichitis. are very 
eiiiiinioiily (|iiile typiciil and unmistakcable. 
.SniMll liliiod-elots make us apprehensive of early 
liiit \Mll-marked -phthisis, or of pharyngeal 
condition'*, or of mitral stenosis: streaks of 
blooil point to acute laryngitis or br<)n<'hitis : pi 
I>lithisis in tlie absence of signs of an aueur\sn 
all inllaiumat ions of iniieous niciiihnincs. and II 
\alur. thoiiiih lis (|iiaiilil\. colouv. and odour- in: 
<\ea\ation. or of an hepatic abscess ruptured int 
empyema. With hepatic abscess the spidurn sonu 
anchovy -sauce appearance. 

In any case of cough with sputum il i 
llii^li'tter, particularly for tubercle bacilli. 

The Aiif of tlic I'liliciil. In babies and (|nite yonng ehildirn niosi ol I he more iinusnal 
causes of cough <-aii be excluded :it once on I lie iimim' lail ol ;imc. bill I lie |ii(siiiee of a 
foreign hodr in the larynx is one of the unusual ones to be rerneinbered. especiall\- if the 
cough has come on suddenly in the midst of Ilea 1 1 h. Rronchilis, bronchi ipneumoiiia. tubercle, 
pneumonia, whooping-cough, and <liplilheria. are far and away the most eoinmou causes 
in lliese young subjects, and owing to the alisenee of e\peel(ual ion lliey ilo nol icvial llieir 




/•■..;. i;l.-.~ki,-.L.'r 

i-\|)Uftoriition, urn 
H, Heart; S, Oris 



illls 



■r-eh 



lr;r-rnopl\sis 
■nwllr. I'lis 
■ iir itself is 
he \ crx SI 



llll 



rlia 



th' 



lirir 
has 



>f hut lit He rliagnosti 
.'geslixc ol' riliseess (i 
garrurcrri . or- slinkiir 
rlrrrosi pirl lioguirnrirni 



lo h: 



'al 



rrrMi roii 



150 COUGH 

presence witliout careful examination of the chest and throat. From infancy to middle 
life, the age of the patient gives but little assistance in determining the diagnosis ; but 
about middle age chronic bronchial troubles, quiet pleurises, growths, aneurysms etc.. 
become increasingly obtrusive, giving rise to a persistent cough, and only careful routine 
examination of the chest will reveal their presence. 

Hoxv long have yon had the eough ? Much information may be deri\'ed from the answer 
to this question, for a cough that lias only lasted a few days, but in that time has become 
sufficiently severe to cause the patient to seek advice, is practically certain to belong to 
the group caused by acute trouble, easily detectable when the chest is examined carefully ; 
whereas, on the contrary, a cough that has lasted some months, and yet seems to the patient 
uncertain in its causation, is very likely to be due to some of the obscurer conditions, 
pressures of aneurysms or glands, etc., which need care to discover. The .r-rays are valuable 
in detecting thoracic aneurysms and new growths, and they are also of service in demon- 
strating phthisical and other lesions in many cases : skiagraphic evidence must never be 
relied upon by itself, however ; it shoidd always be interpreted in terms of the other clinical 
data and physical signs. In an obscure case, however, .r-ray screen observation should 
not be omitted, as it will now and again be the only means of clearing up the diagnosis. 

\Mien does the eough eome on ? A cough in the morning only is suggestive of bronchial 
catarrh with accumulation of secretion during sleep. A cough on getting into bed suggests 
laryngeal irritability or a long i)endulous uvula : but one that wakes the patient alter he 
has gone to sleep makes one apprehensive of phthisis in the absence of other indications 
of obvious acute chest changes. A cough on exertion suggests heart weakness, and in 
determining the presence of this, the finest discrimination is required in auscultation, for 
these are typically the ca.ses of morbus cordis without a bruit in which frecpiency of rhythm 
and good dilTei-enliation of the first and .second sounds are all ini])ortant for a diagnosis. 
.Shortness of breath will generally be a marked symptom associated with the eough in these 
eases (see Breath. Shortness of, p. 87). 

Has the iviee altered since the cough appeared ? Laryngeal inflanunations or jiaralysis 
of a vocal cord are suggested by an affirmative answer, and the larynx must be examined 
carefully, the more carefully the more nearly the patient is approaching to the period of 
life when growths are more common. 

Cough and Vomiting. — These two complaints are not infrequently made together 
by patients, and there is a very useful but often forgotten question to put, viz., " Are you 
sick indei)endently of the cough ? or do you cougli till you are sick ? Yes to the first sug- 
gests stomach trouble ; yes to the second suggests bronchial trouble or whooping-cough. 

Fred. J. Smith. 

CRACKLING, EGG-SHELL.— This is a condition closely allied to Crepitus (p. 152) ; 
if subcutaneous emphysema, arthritis, and tenosynovitis can be excluded, it is nearly always 
a .symptom cither of osteosarcoma, if it occurs in connection with a long bone, or of hydro- 
cei)halus or craniotabes in the case of the occipital or other cranial bones. The .r-rays 
may assist the diagnosis (p. 673) : if there is a tumour connected with the end of a long 
bone which exhibits egg-shell crackling with or without pulsation, it is almost certainly 
an osteosarcoma. Herbert French. 

CRAMPS arc involuntary tetanic nuiscular contractions accompanied by sharp pain 
in the voluntary muscles involved. Temporary paralysis of movement, partial or com- 
plete, is often associated with cramp. Similar painful spasms of the involuntary muscles 
are referred to as colic. In most instances, cramps result from over-exertion of the affected 
muscles. The eram]i comes on at once, or after a short delay, or when the attempt is next 
made to use the muscles involved. The most striking example of this is swimmer's cramp ; 
in this the victim is overtaken suddenly by painful spasm and paralysis of the nniscles of 
the leg or legs, or of the legs and arms ; he is likely to drown unless help is .speedily forth- 
coming. Similar but less extensive cram]3s are not rarely experienced by persons taking 
part in the more violent of outdoor games — football, hockey, lacrosse, etc. : some par- 
ticularly sudden or violent effort may be followed by cramp in the thigh- or calf-muscles. 
Similar cramps of the legs are familiar to rowing men and ballet-dancers. Certain people 
have a great proclivity to cramp during the night, and it seems to return with less and 
less provocation the more often it is experienced. Stokers and iron-founders who do heavy 



CRAMPS 151 

bodily work in much overheated atmosphere are liable to heat cramps, severely painful 
spasms in the muscles of the limbs and abdomen, in attacks lasting for many hours and 
followed by great weakness. The diagnosis of cramps due to over-exertion, directly 
associated as they are with a definite history of muscular strain, should not be difficult. 
They rarely become so severe as to prevent their victims from continuing to take part in 
the occupations that provoke their occurrence. 

It is f|uite otherwise, however, with jjatients who are afflicted with the so-called 
profcssioiiiil iriinips or occupation neuroses that result from chronic strain and over-use 
of certain groups of muscles. They occur in such persons as writers, typists, telegraph 
operators, compositors, painters, tailors, seamstresses, dairymaids (from milking cows), 
pianists, flute-players, violinists, 'cellists, drunuiiers, blacksmiths, file-makers, cigarette- 
rollers, and so forth. In all these employments, |)articular groups of muscles are in constant 
and special employment. If they are overworked they may become the seat of cramps 
and aching i)ains — professional cramps — as soon as they are used : their movements lose 
their delicacy, and become inco-ordinated and spasmodic. A fine tremor is very connnonly 
to be observed in the affected limb. It is probable that over-use alone is not enough to 
set up these eramjis. Anxiety, ill-health, local injury or disease, and the inheritance of 
a neurotic tcm])crauient, all contribute to the establishment of professional cramps. These 
cramjjs have also been recorded in other occuiiations, and as affecting other grou|)s of 
nuiscles : in treadler"s cramp, the hamstring nuiseles and glutei are affected ; in cornet 
player's the tongue, in watchmaker's the orbicularis oculi, may be attacked. As a rule, 
the diagnosis of a professional cramp is not hard, but it is necessary to make sure that 
neither organic nervous di,sorder nor local di.sease is present. Thus the physical signs, 
f JKMigli hardly the symptoms, of writer's cramp may be present in such diseases as paralysis 
agitans, dissemiiialed sclerosis, tabes, general j)aralysis ; brachial neuralgia niiglit sinuilate 
the neuralgic loniis of occupation neurosis, but it is free Ironi (iam))s. .\gaiii, atreelions 
of the joints or of the tendons at the wrists, such as chrome rlieumatism, rheumatoid 
arthritis, tenosynovitis, tuberculous infection, may all give rise to pain in, and interfere 
with the movements of, the hand. Again, writer's cramp may be so much feared by nervous 
patients that their right hand may become so stiff, or weak, or ))ainful, that they can no 
longer write : ohjeeti\e signs of the cramp, however, are lacking in such cases, which are 
cured by the re-establishment of the patient's self-conlideuee. 

Cramps are the main feature of tetany, a disease eharacteri/.ed by the occurrence ol 
paioxysmal or continued tetanic spasms of the extremities, and increased excitability ol 
I lie nerves and nuiscles to electrical or mechanical stimulation. Tetany occurs in many 
diircrcnt conditions, and at any age. In infants and young children it is a complication 
of rickets, improper feeding, and acute gastro-intestinal disorders, either with or without 
diarrho-a and xoniitiiig. Mpidcinies of tetany in young aduMs, pnil)a.l)ly resulting liiiiii 
liioil-poisonjng, lia\i- been dcse;il)cd on the t'ontinent, though not. apparently, in (ileal 
Hi'ilaiii, In mirsing woiniii. tetany may follow jjrolonged laclalidii : or it inaN dcNclop 
during picgnaney and recur in successive pregnancies. It may result from I he riino\al 
of too much or all of the th>roid gland in either sex. Tetany complicates a certain pro- 
portion ofjllie cases of gastrectasis, occurring whether the dilated stomach has been waslie<l 
out or no. A few instances are on record in which tetany followed the acute spicilic levers, 
enteric li\ ir. or- poisoning by chloroform, lead, or ergot . In line, it may be said that tetany 
is u--ually <lue to acuti- or clironie digestive troubles, the painful spasms being evidence 
111' I he al)s(uption of some lux in Irom the gastro-inlcsl inal had in inosi (•a>cs. The cramps 
III Iclariy are maitdy in tlir i\l i<inities and parowsinali lli(\ ina\ ((inliniie, however, 
lor lidurs or days, and are \(ry painful. During Hie spasms. Ilic lingers arc extended at 
llir Icrminal ami llexed at the inetaearpophalangeal joints ami pressed together, while tin- 
Ihinnh is addueled and llexed into the palm, so thai tli<' so-called 'accoucheur's hand' 
{l''iii. 1. p. :i) is pniducrd. The wrisi ami elbow are llexed. I he aims lieing usually folded 

over the chest ; exeeplionall> I he cIIkiw \ he extended slillly. The Iocs are drawn 

together and llexed. the loot is arched and turned inwards, and the ankles and knees 
extended, (siially the limbs only arc involved, but in severe cases cram[)s occur in the 
face, neck, and even the trunk, when respiration may be embarrassed seriously. The rigid 
nuiscles are very tender to the touch. Three special signs are present in the intcr\als 
between the attacks of tetany, and are valuable in diagnosis : these are Trou.sseau's sign. 



152 CRAMPS 

or reproduction of the paroxysm by nuiiuial compression of the nerves or blood-vessels 
supplying the affected parts ; ]<;rb"s sign, or hyperexcitability of the motor nerves to 
electrical currents (0-5 to 2-0 milliamperes) ; and Chvostek's sign, or reproduction of the 
spasm in the facial muscles by tapping either on the muscles themselves or on the facial 
nerve. Tetany must be diagnosed from letmius, in which the spasms begin in the head 
and neck, and trismus is an early symptom ; and from strychnine jjoisoning, where the 
spasms are clonic rather than tetanic, and affect the whole body, and not the extremities 
primarily or principally. In the carpo-pednl spasms of rickety children or of infants with 
severe gastro-intestinal catarrh, the cramps are similar to those of tetany, but are tran- 
sient, and perhaps affect the hands only, or the hands and arms. Such spasms may justly 
be regarded as identical with mild tetany. Hysterical tetany occurs, and is to be distin- 
guished from true tetany by its association with other hysterical stigmata on the one 
hand, and on the other by the absence of Trousseaus and Chvostek's signs. Hysterical 
tetany may also, perhaps, be distinguislied by its failure to respond to the exhibition 
of calcium salts ; the .most recent view of true tetany regards it as the expression 
of Iiyper-excitability of the nerve-cells due to lack of calcium salts, and connects 
it with the ))arathyroid ghuuls by sui)i)Osing that they control tlie caleium-metabolisiu 
of the l)0(ly. 

|{elerenee may again be made to the fact that cramps are prone to occur in patients 
il(l)ilitated by the acute fevers or enteric fever; severe cramjjs in the legs and arms are 
olten a liighly troublesome feature of the convalescence from cholera. In many chronic 
diseases noctiu-nal cramps may give rise to no little distress, or may interfere seriously 
with sleep : in gout, chronic Bright s disease, urwmia, alcoholic neuritis, and almost any 
chronic wasting disorder, complaint of cramp is not infrecpicnt, but in such instances more 
serious signs or symptoms ot disease will be evident. A. J. Jex-Blala\ 



CREPITUS is a term generally used to denote the grating or crackling sensation and 

noise jiroduced wlien two ends of a broken bone 
grate together. It is the most conclusive sign 
of a fracture : but it causes the ])atient so much 
pain that whenever the a'-rays can be employed 
attempts to obtain crepitus should not be made 
with any vigour. Apart from fracture of a 
bone, crepitus is also to be felt and heard in 
joints affected by dendritic synovitis, or still 
more so in cases of oslco-artliritis : the term 
■ silken crepitus ' has been used for tlie sensa- 
tion felt on moving such a joint, comparable 
to the rubbing together lietween the fingers of 
two pieces of stout silken ribbon. Tenosynovitis. 
especially around the flexor tendons at the 
wrist, may also produce a very marked feeling 
of crei)itus, especially in cases where the tendon 
sheaths contain melon-seed bodies. 

\\hen there is an enlargement of a bone 
without fracture, and when on palpation a 
feeling of crepitus or egg-shell crackling is 
obtained, it is an indication that the tumour is 
a deposit of secondary carcinoma or a ])riinar\ 
rarefying osteosarcoma, which may sometimes 
be felt to pulsate also. The diagnosis may be 
/'•/.;. (52 -Ski. lt;itii of :i -rn«iii in ii.f iiMiiicnis in :i assistcd by tlic usc of the .r-Tays (Fis- 62). 
'•T.n '-"um' M,inl!ni '' m"'i'. '"••!'" ^u.n In i'i,"'!"",!i 'i " Harcfaction of the bones of the skull, either 

ary di'|i"-ii "I < i imit i. ii , , II. ,1 , u, ii,,.i -rn ,.( as the result of syphilitic lesions in adults, or of 

tip liiiniH.i '■-'''J'y^'|^^'|^'.||'^^")|^''y^'^"J!''|^^'^^^.[|"^^ lii/droccplialus or craniotahes, especially in the 

occipital region of congenital syphilitic and 
rickety infants, may make the skull bones so thin that they readily bend on pressure, anil 
sometimes the result is a sensation of crepitus. The diagnosis is generally obvious. 




CTKVATURE. SPINAL 153 

Quite apart from bony, arthritic, or synovial changes, a characteristic fecHng of 
crepitus may be felt beneath the skin when gas or air has accumulated in the subcutaneous 
tissues as the result of surgical KMrnysKMA (p. 203). Ilerherl Frciirh. 

CRUSTS ON THE SKIN.— (See Scabs, p. 599 .) 

CUD-CHEWING. -(See Meryci.sm, p. 388.) 

CURSCHMANN'S SPIRALS consist of a liiglily refraetilc central fibre, and a 
sinuous wa\y sheatli of mucus. They may be half an inch in length, but they are very 
slender. Tliey occur in the s])Utum of i)atients suffering from true spasmodic astlmia. 
and they may be associated witli cosino|)hilc corpuscles and Charcot -Leyden crystals. 
They are pretty objects, best seen in fresh sputum, but tlieir diagnostic significance is very 
limited, first because they are so often absent in cases of undoubted asthma, and secondly 
because they have been found in bronchiolitis without asthma. They seem to be casts 
of the finest bronchioles. It is probable that, if there were doubt as to whether a given 
case were one of ]>rimary emphysema and bronchitis, or of spasmodic asthma that had 
led to cm])hyscma and bronchitis, the occurrence of tyjjical C'urschmann's spirals would 
point to the latter. There are, however, other means of arriving at the same conclusion, 
particularly the history, the age at wliich tlie first attack began, and the presence tiv 
ab.sence of Eosinopuim.v (p. 219). Herbert Fre»cli . 

CURVATURE, SPINAL.— In the diagnosis, the first thing is to distinguish between 
latcial and antero-jjostcrior deformities ; but in a good many cases scoliosis or lateral 
ciuvaturc is complicated by antero-iiosterior deformity, kyphosis, or lordosis as well, and 
in a few instances of angular kyphosis due to caries there is some lateral deviation, which 
is generally nuich more abrupt than is the curve of scoliosis. A good way of demonstrating 
lateral curvature is to pencil the skin over the spinal processes. 

LATERAL CURVATURE. 

The following arc the niosl irii]Hirtaut causes of lateral curvature : — • 

Iric.|ii;ilil\ III Ihi- I(iil:IIis iif the ioucr limbs I Paralysis of the muscles of the back, as in iufan- 

\\( .ikiicss ol I III- mhimIcn of tlic luuk associated I tile paralysis, peripheral neuritis, especially 

with bail lialiits of standing; di' sitting ' that following diphtheria, and some of llir 

( MirviiiL' li<:i\ V weights with one .■uni or on nnc MinscMlar dvslropliies 

sliiMil(l( 1 ' ' SiMivclliiii; (if (iiie side iif the chest as the result 

Hirkcts (if ciiiiiyi ma or lilnnid Inng 

\\i\-ii((k. (11- (itlier causes of asymmetry of the | IIy>tiria 

head anil shoidders. such as .SpreiigePs ' 

-luinldcf 

Iiiniiiiililji of the liii'itlis of the hnccr linilis is oiic of I lie (■(iiiuiioiiest causes of laleral 
eiir\aturc ; therefore it is \ery iinporlaiil (o litid out al once if (lie legs arc e(pial. The 
most reliable and easy method of dclciiiiiniug this is to gel I he palient to stand up with 
bolli knceV straiglit aiul witliout resting a hand upon anylliing. Tlie ol)server then stoops 
in fi'dtil of tlu' ])atient and jjlaccs his thumbs, with their extremities upwards, exactly 
u|ioii the proMiinenee of each anterior superior >.piiie. The eye can then detect even a 
slight difference in tlie level of the two s|)ines. This method is hir m<nc reliable than 
measurement from the anterior superior spines to the malleoli. .Moreover, the latter 
method does not show shortening due lo llcxion and adduction of the hip Joint. Further, 
I In- fool may be lixed in a position of talipes c(piimis, which may make a shorl limb 
:i|ipai-eiill\- l(ini;cr llian ils fellow, so that llic aiilcrior spine on the eorrespoiiding side 
may lie clcx .'it cd . When llic anterior spines arc (in :i diricrciil level, tile truid< leans 
louards the lower spine, lint ill older lo iiiaiiitaiii llie erect |i(isiti(ili the upper |iail of 
the li(id\- hecoiiies Hexed to the opposite side. Thus, the spine in the limibar region 
(l( \(lo|)s a ciir\e with its convexity to llie side of the shorl limb. Liiteral cur\alure due 
1(1 a shortened limb, in its early stages, is corrected al oiiee by coinpeusating the shortened 
limb, and it also disajipcars when the ))atient sits on a Hal le\il surface. In the al)sencc 
of iiieipiality of the limbs, wiinciilar urnlnirss is by far tlic most common cause of 
lateral eiir\aliire. The spine does not lieeoine slraiiilil when the palieiil sits (Ul a Hat 



154 CURVATURE, SPINAL 

level siirfaee : hut in the early stages of the deformity the shape can be corrected some- 
what by muscular effort. 

Asymmetry of the chest following upon empyema or fibroid lung is easily detected. 
The shrivelled side is generally less resonant on percussion, and there are other signs of 
pulmonary disease. 

Scoliosis secondary to wry-neck is usually slight, and limited to the cervical and dorsal 
regions. In growing youths the carrying of heavy iveights with one arm or upon one shoulder 
is a common and important cause of scoliosis, and it is therefore necessary to go into the 
question of occupation and liabits. For instance, nursery-maids and butchers' boys are 
very apt to develop lateral curvature as the result of carrj-ing burdens upon the right arm. 

The lateral curvature due to rickets is recognized by the unusually early onset, during 
the first or second year, and the signs of rickets in other parts, especially thickening 
of the lower end of the radius. The direction of the primary curve is sometimes explained 
by the pressure of the arm of the nurse who carries the baby too exclusively on one arm. 
Actual paralysis of the spinal mascles is a rare cause of scoliosis, and is to be recognized 
by the wasting of the spinal muscles, especially when this is more marked on one side. 
The sinking of the muscles due to rotation of the spine must not be mistaken for wasting. 
There is usually paralysis of other muscles, especially those of the leg. Scoliosis is often 
seen in the various primary muscular atrophies (p. 513). and in Friedreich's hereditary 
ataxy (p. 51'2). 

Peripheral neuritis as a cause is nearly always due to diphtheria or sore throat. Tlic 
history, may indicate this, or there may have been other post-diphtlieritic paralyses, 
notably that of the soft palate, with nasal voice and regurgitation of lUiid through the nose. 
Cultivations should be taken from the throat, and the Klebs-LiWUcr bacillus {Plate 
XXV HI, Fig. L. p. 614) may be found if sought early enough. Ocoasii)nally the abdominal 
muscles may also be paralyzed in these cases, and this is a contriljutory cause of the 
curvature. 

ANTERO-POSTERIOR CURVATURES. 

These may take the form of (1) Kyphosis, (2) Lordosis. 

1. Kyphosis or " hunip-baek," means a bending forwards of the upper part of the 
back on to the lower. The curve may be (a) Angular, and limited to a small portion of 
the back ; or it may be (h) Diffuse, or even general, extending from the coccyx to the 
eraniiuu. 

(a). Angular Kyphosis. — The causes of angular kyphosis are: — (i) Tuberculous caries 
of the vertebnc ; (ii) Growth of the spine ; (iii) Hydatid disease of the vcrtebrse. 

(i). Caries is by far the conmionest cause, and it is very imj)(>rtant to recognize the 
disease before the deformity becomes well marked. I'nfortunately, it may be treated 
lor a long time as stomach-ache or intercostal neuralgia, because the pain is referred to 
the abdomen and the intercostal regions. During its active stages it is easy to recognize 
it from its classical symptoms and signs. The patient avoids all jerky movements, walks 
with a stooping gait, and grasps with the hands any convenient article of furniture. The 
sjiine is tender on percussion, also on pressure ujjon the head or shoidders. Local rigidity 
of the back is noticed when the patient attempts to stoop. In later cases, paralysis of 
the legs may complicate the deformity. In the quiescent stages, the diagnosis is based 
on the characteristic local deformity and rigidity. Skiagrams, especially (hose taken 
from side to side, may afford material help by showing evidence of destruction of the bodies 
of the vertebnc {Fig. 195, p. 460). In some cases, lateral curvature may complicate or 
follow caries, and then the diagnosis is not easy. The disease may have affected the 
bodies of the vertebra; imevenly. leading to some lateral deviation, which is usually rather 
abru])t and associated with the local rigidity characteristic of caries. 

(ii). Groivth of the spine is a rare cause of angular curvature. Ra])idly developed 
curvature in a patient after middle age may be due to secondary carcinoma in the bodies 
of the vertebra-, and bearing this possible cause in mind, the surgeon should go carefully 
into the history, and examine every ])ossiblc source of primary carcinoma, particularly 
the breast. Primary or secondary sarcoma may also lead to deformity of the spine, and 
in some cases an x-v&y examination may give evidence of the development of new bone 
in the growth, or of the absorption of the vcrtebr;c. 



CURVATURE, SPINAL 



155 



(iii). lii/dalid disease is a very rare cause of spinal curvature, and it is usually not 
limited to tlie spine. 

(b). Diffuse KfipJiosis. — The back may be bent forwards in a uniform curve extending 
from the coccyx to tlie cranimn. This variety is common in rickets, owing to the premature 
assumption of the sitting position when the bones are soft and the muscles of the back are 
weak. When the patient is lying prone, the deformity can easily be corrected by raising 
the legs. Moreover, there are other signs of rickets, such as enlargement of the lower end 
of the radius, beading of the ribs, and delay in the erui)tion of teeth. A similar deformity 
arises from muscular iceakness due to other causes, such as idiocy and congenital spastic 
paraplegia. In all of these there is an entire absence of rigidity of the spine. An extensive 
an<l luiiform curve, affecting the cervico-dorsal region, is common dining adolescence, and 
is due to muscular weakness, la/.v habits, and the carrvin" of luaw weights. In its earlv 



^^^^^HmB^L'3^^1^^1 


^pj 


^^^IV 1 iff'S'' '^ ' ' 


Ipl 


\ 


^^m 


■—} 






stages llii- ilduiinity is easily icdiicililc, :iii(l ;is :i rule is (•(iMip<iis;il( il by ;i iu:irked lordosis 
in the luirilj;ir region, and sonic lilliiig b:i(k\v:inis of Ike occipul. II is ol'leii associated 
witli hilcnil curvjiliirc, and in some cases iii:iy be Jiartly due to shortness of siglil. The 
eoiiililidn is ilisliiigiiislicil riiiiii caries by llic dilTuseness of the curvaltne, llic aliseiicc of 
pain and local lenderiiess. and llie cornpaial i\e suppleness of the back. 

Kyphosis due lo s/)())iili/lilis (h'fdniiuiis or to oslcilis ilcfiiniKiiis (h'iiis. (i;t and (it) is ol' 
a more uniform character without complicating lorilosis, and the deformity is iricdueible. 
There is generally cviilence of the disease in other parts, such as ostco-arthritis, or the 
bending of the legs, and increase of tlie si/.e of the head, which arc due to osteitis deformans. 
I'orlers carrying heavy weights on the np|icr p;irl ol the ]i:\rk prcrniil nrclx (l(\il<ip the 
kyphosis which is usually asso( iiilcd uilh old ;inv. Tiny tncininlly li:i\c a bursa over 
the seventh dorsal spinous ))roeess (/•'/!.'. (!."•). 



156 



CURVATURE. SPINAL 



2. Lordosis, Hollow-Back. — This deformity is only common in the ]uml)ar and 
lower dorsal reirjon. The natural hollow of tlie ]oin is exaggerated, and usually there is 

either primary or compensatory kyphosis in the 
cervico-dorsal region {Fig. fiO). Lordosis is 
rarely primary, but it may be so in the early 
stage of lumbar or lumbo-dorsal caries in 
children, when the real cause of the deformity 
is a])t to be overlooked. Tlie abdomen is very 
prominent, and the back is not only hollow, 
hut rigid and tender. Pressure upon the head 
also causes pain in tlie back. In some cases 
the deformity is exaggerated by induration or 
suppuration in the psoas muscle, which com- 
plicates this disease. I.,ordosis is not uncom- 
monly due to weakness or paralysis of tlie muscles 
of the back {Fig. CO). It is particularly impor- 
tant to look for other evidence of primary 
muscular dystrophy. The upper part of the 
back is then thrown backwards to facilitate the 
maintenance (jf the erect position. Lordosis is 
often secondary to the flexion of hip disease. 
which must not be overlooked. Limitation of 
movement — especially of rotation of the hip 
joint — and wasting of the thigh, serve to demon- 
strate the existence of this disease. Lordosis 
and the waddling gait may be the first indica- 
tions of congeniidi dislocation of the hip. In 
this condition, whicli is 
almost confined to the 
female sex. the erect 
position is maintained only 
by throwing the shoulders 
backwards to an unusual 
degree in order to bring 
the trunk in a line with the heads of the femora, which are dis- 
located backwards. The suspicion of congenital dislocation of the 
hip may be confirmed by skiagraphy, by the gliding movements of 
the head of the femur upon the pelvis, the unnatural width of the 
lii|)s. the hollow appearance of Scarpa's triangle, and by palpation 
of the head of the femur upon the dorsum ilii when the thigh is 
flexed, strongly addueted. and inverted. Contortionists usually have 
a good deal of lordosis owing to the unnatural suppleness of the 
lumbar spine and the elongation of the hamstrings. In all these 
conditions, the back is supple, and can be restored to its natural 
shape by placing the patient in the supine position and Hexing 




Fiif. IJ5. — Deal porter's bursa 



■rtebra p 



the thighs. 



/?. P. noalaihls. 




CYANOSIS, EXTREME.— Extreme cyanosis, blueness. or livi.l- 
ity, is gencially most marked in the face : next in the extremities. 
especially the hands, feet, ears, and penis : and least in the trunk. 
Cases in which it is a prominent symptom may be divided into two 
main groups, according as the cyanosis is present at or soon after 
l)irth. or occurs later in the life of a patient originally free from it. .Myopathic lordosis. 

Congenital cyanosis of extreme degree is nearly always due to 

malformation of the heart, particularly pulmonary stenosis {Fig. 07). Patent septum ven- 
triculorum may also produce the symptom, though not in so marked a degree, whilst 
patent ductus arteriosus, when it occurs by itself, is generally not associated with 
cyanosis at all. These three conditions all give rise to loud universal bruits, of which 



CYANOSIS. EXTREME 



157 




that due to pulnionary stenosis is purely systolic, with its niaxinuim intensity in the second 
left intercostal space close to the sternum : that due to patent septum ventrieulorum is 
also systolic, but has its maximum intensity lower down the sternum, usually between 
the two third spaces or fourth ribs : whilst the bruit of i)atent ductus arteriosus is not 
purely systolic, but continues through both systole and diastole, with its maximum 
intensity at the time of the second sound, and it is best heard in the third left intercostal 
space, about half an inch out from the sternmn : all these bruits may or may not be accom- 
panied by a correspondinu thrill, the latter generally 
being least marked with patent septum ventrieulorum. 
Extreme Cubbing of the Fingers and of the 
toes accompanies the cyanosis in most cases {Fig. 46. 
p. 111). In addition to these three types of con- 
genital heart disease, there are other cases in which 
extreme cyanosis, with or without clubbing of the 
fingers, occurs without any definite bruits, and the 
diagnosis of the nature of the lesion can only be 
guessed at. There may or may not be transposition 
of the great vessels or flf the viscera at the same time. 
Sometimes there is a single large vessel, the pulmonary 
artery coming off from the aorta : or there may be 
only one ventricle, or a single auricle. It is almost 
impossible to decide between the various possible 
lesions, unless there is one of the definite bruits just 
described. Anomalous cases seldom survive, but some 
cases of pulmonary stenosis or patent septum ven- 
trieulorum reach adult life, and ])atent <luctus arteri- 
osus often gives little inconvenience to the patient at 
all. It is to be remembered that patent foramen ovale 
is quite undiagnosable, that it causes no .symptoms, 
and is present in a large percentage of normal people. 

Cyanosis developing in children or adults who have hitherto been healthy, is generally 
due either to laryngeal or tracheal obstruction, to lung lesions, cardiac failure.- obstruction 
to the superior vena cava, or to some alteration of the blood itself, such as is found in 
splenomcgalic polycytha-mia. metha'Uioglobina-mia. suli)h-luemoglobina-mia. or the later 
stages of diseases associated with extreme loss of Huid from the tissues, especially cholera 
maligna. Tlic differential diagnosis is usually easy up to a certain ])oint ; not a little 
cyanosis may result from taking certain drugs either in large (piantities at a lime, <u- in 
less quantities continually — veronal, trional. sulphonal, and aeetanilide in paiticular. 
The urine in these eases oflen reduces Kehiing's solution, and may conlain metha'mogjohin 
recognizable by the sjHctroscopc. The diagnosis depends on a knowledge of the drug that 
is being taken. Caaes nS pancirntili.s often exhibit a peculiar cyanotic hue. The fact of 
laryngeal obstructiov is generally obvious from the stridor, and from the way in which the 
larynx moves forcibly up and down with respiration. The cause of the obstruction may 
be less easy to determine. In a child, a digital examination of the back of the mouth 
should not be omitted, lest there be a post-pliaripigcal ahsrrss or a foreign hoili/ : in the 
absence of this, the most probable cause is iliplillicrifi : though it may be dilliciilt to dia- 
gnose forthwith belwcen lari/iigilis icilh inlrrniittetil spasm, lari/iigiswiis siriiliiliis. acute 
obstructive laryngitis, and diphtheria. Swabbings should be taken from the throat as far back 
as possible, and examined baeleriologleally. The bacillus of diphtheria {I'late XXVIII.Fig. 
h. p. (il !•) may be found ou direct examinalion of films stained by Xeisser"s method : but 
sometimes the\ eannol be found until eultivatiotis have been made, and this takes upwards 
of twenty-four hours. If there has bi-en no obvious cause for catarrhal laryngitis, such 
;is the inhalation of irritant gases or a re<'ent attack of acute l)r()ncliitis affecting the large 
tubes, it is better to assume that the condition is diithfheria until it is |)rovcd not to be so. 
The occurrence of other cases in the same house, or in the neighbourhood, may assist the 
diagnosis. .Another condition which may simulate diphtheria from the extreme dyspnfca 
and cyanosis that result is the iiihalatinn (if a foreign liody. such as a button, small shell, 
piece of food, a tooth, and so on : or ohstruelion to the traelua by a bulging cascou.'t 



pulraonary stenosis 



158 



CYANOSIS. EXTREME 



gland {Fig. 68). In an older person, acute sufforalive lan/uaitis due to pneumococci or strepto- 
cocci is associated witli extreme cyanosis of rapid onset. Tracheotomy is necessary, and 
tlie diagnosis is arrived at upon bacteriological grounds. When similar acute infective 
changes occur, not in the larynx only but in the root of the tongue as well, tlience infil- 
trating the deep structures of the neck, as 
left main bronchus ju angina Ludovici. cyanosis and dyspnoea 

scarcely visible on account niay be vcrv marked : the diagnosis is 

:>fthe huig.ng gland above it suggested by the acute brawny swelling 

of the neck and by the changes in the 
floor of the mouth and tongue. Severe 
dyspnoea and cyanosis may accompany 
goitres, whether simple, exophthalmic, or 
malignant : tlie attacks may be paroxys- 
mal even though the thyroid gland itself 
does not seem to vary in size ; or the 
cyanosis and dyspnoea may be continuous 
when there has been rapid enlargement 
of the gland from rarities such as hspmor- 
rhage into it. acute suppuration in it, or 
from progressive and extreme fibrosis of 
the organ such as is seen in ligneous thy- 
roiditis, or Riedel's disease (see Thyroid 
Gland, Enlargement of, p. 721). It is 
difficult to inspect the vocal cords in a 
child : but in an adult this is easier, and 
direct examination serves to distinguish' 
between acute or ulcerative lesions of the larynx and laryngeal paralysis ; the latter, some- 
times the result of syphilitic degeneration of part of the vagal centre in the medulla, is 
apt to produce bilateral abductor paralysis with adductor spasm, which may come on acutely 
and simulate acute asphyxia from a foreign body. Tuberculous, syphilitic or malignant, 




A larg, 
inward bulge of \ 

the left wall "ivf 

of the trachea \ 
caused by a caseousi 
gland fvhich is embeddt 
in the bulge "- 



Fig. 68. — Broiichoscopic appearance of 
compression from enlarged glands. There w 
And cyanosis in tliis case, relieved at one 
the bronchoscope. 



a c:xse of trachea 
.s extreme dyspntea 
'by the passage of 




e care 

h for 
nil 



x'uriolous, leprous, lupoid, and traumatic tilceration of the larynx, may any of them become 
acutely infected by inflammatory organisms, and lead to comparati^•ely sudden and severe 
laryngeal stenosis with acute cyanosis : the diagnosis will depend upon the history, bacterio- 
logical examination, and direct examination of the vocal cords. Bright's disease has 



CYANOSIS. EXTREME 



159 



sometimes caused similar symptoms, due to acute oedema of the larynx, and potassium 
iodide may do the same in those who are particularly prone to iodism. Knee-jerks should 
be tested, and the pupils examined, lest acute attacks of dyspnoea with cyanosis simulating 
laryngeal obstruction are due to the laryngeal crises of tabes dorsalis. 

Groicths of the lung, particularly if they give rise to pleuritic effusion or to obstruction 
of a bronchus, may cause progressive cyanosis : the diagnosis is not as a rule easy in the 
earlier stages, but if there is evidence of progressive interference witli the structures within 
the thorax, with ultimate stenosis of the superior vena cava, and the results of this, namely, 
oedema of the face and arms, together with cyanosis of these parts out of proportion to 
any similar change in the legs, the diagnosis lies between growth, aneurysm, and mediastinal 
fibrosis. The .c-rays will sometimes be of material assistance in deciding. A rare but 
very alarming complication of thoracic aneurysm is for the latter to open suddenly into 
the superior vena cava : the result is acute dyspncca. extreme cyanosis of the face and 
hands, and bloated-looking swelling 
of the head. face, neck, arms and 
upper part of the chest and back 
(Fig. <>U). The diagnosis is suggested 
at once by the suddemiess of the 
onset of the graver symptoms : 
though these have also been pro- 
duced in rare cases by such lesions 
as sudden liiemonliage into the mrdia- 
stinum or thi/ttiiis gland, or similar 
heeinorrlidge into an inlr/ilhoratic 
sinionia or other new growth. 

Phthisis, in the later stages, 
particularly when it advances 
rapidly and leads to generalized 
caseous bronchopneumonia, qauscs 
extreme cyanosis in .some instances. 
The diagnosis will generally have 
been made long previously, from 
the symptoms, such' as ha-moptysis. 
cough, and wasting : from the ab- 
normal physical signs which started 
at the a|)iccs of the lungs and were 
progressive : and from the discoverv 
of tubercle bacilli and clastic lil)r(s 
in the sputum, though there arc 
many cases of miner's phthisis (Fig. 
70), or pncumonocouulris. in which 
the lung trouble may he extensive, 
yet tubercle bacilli cannot be 
found: there is doubt as to whether ^ 
this condition is always tuberculous ! 
and not sonu-tiiiics syphililic. ' 

I'nciimothora.r. when il cdiius 
on suddenly in a patient who has liai 
and cyanosis, which present l\ pass olT: 
cause is generally tubercle. 

F.mli(dism of the lung, if the artery i 
so that the patient hardly has time t( 




till' liillH 


U'ul'l iMini - 1 ' '< 


■■'•- liistorv 


niiiri liii.l 


WUtJ :l lllllr [ I. > ... 


.... Now 


S|iUU.I]l 


I.Ul «il M .1 1 


I.I. iiiherde 


iths llftOI 


tlip skmj.-r:irii «;,» t: 


ken. 


,.SA-ia//r«/ 


1 bn Dr. C. Thurstai 


Holland.) 



no symptoms hitherto, leads to acute dyspuiea 
the pliysieal signs are pathognomonic, and the 



iC<-hMl((l is ol large si/.c. may cause Middin death, 
become {vanoseil ; wlicu the cnilxilus blocks a 
smaller \<ssel. Ii\idity. dyspncca, intrathoracic pain, and lucmoptysis arc the most promi- 
nent symptoms ; the diagnosis is suggested by the suddemiess of the onset in a ease in 
wliieli there is a cause for embolism, particularly thrombosis of a vein such as the femoral 
or iliac, or a recent surgical operation in the neighboiuliood of a large vein such as those 
m the abdomen, or otitis media with lateral sinus thrombosis, or a cardiac Icsiorrsueli as 
infective endocarditis of the right side of the heart. Tlurc may bi- no ahnornial plivsical 



160 



CYANOSIS. EXTREME 



signs ; but sometimes the resultant infarct may be detected by tlie impairment of percussion 
note, the deficient vesicular murmur, and the development of a rub over it. 

In childhood, the commonest lung affection to produce extreme cyanosis is broncho- 
pneiimoiiia ; the diagnosis is generally obvious, though it is not always easy to determine 
whether, in a case in which there is some evidence of laryngitis at the same time, tlie 
cyanosis is due mainly to the laryngeal obstruction or to the intra-pulmonary lesions. 
Each may cause extreme sucking in of the intercostal spaces and convulsive movements 
of the chest as a whole : but the best measure of the degree of laryngeal obstruction is 
the violence of the up-and-down movements of the larynx itself. There may or may not 
be empyema associated with bronchopneumonia ; but the degree of cyanosis will not help 
to distinguish between these two ; needling of the chest will be resorted to when there is 
ground for supposing that empyema may be present. Severe bronchitis and emphysema 
in middle age often lead to marked cyanosis and orthopncea, owing no doubt to the failure 
of the right side of the heart to which the lung trouble gives rise. The over-distended 
condition of the chest, its small difference between maximum inspiratory and maximum 
exj)iratory girths, the deficiency of the vesicular nmrnuir, the rhonchi all over it, and 



^ 


-^f '^' -i '1 


- 


-ICt^TIE T-CHT igT!: 


#f#S 


fFlf 


' . r-{. 1 i 






1 


j l" 1 1 1 , 1 I 




\ ' ' 1 1 M .'^ 1 










_ 


i..-r '^'^ 








1 J 1 1 










t 




•" 




' 


_, 


r 1 1 






^9S,.<.III(t 


»K«ll2tlZll2IC»^ lOaiOb l[M({HC*Mlt[ 


mJi, 




»(.<,» 


ra2» 


JU8BS* 8&9f8*OH0fl' 


MeOSOjBOflOlSl 


608( 






tn\n 


' 1 






3. ot2< 




|4>lfr4C|M44*:|«flu44 






fl0354< 




563- Kir 30(30 B( 






aw4 








1 1 ii 






1 ' 


' 


' r ! 1' 






r 1 


\ 





MAR 


M 31 


AfRiL 1 2_ 1 1 _ 


4- 


' • ■ 1 "l \ '' 






3- ^ 




,0-. 


"^ 


"^ 


1 , 1 1 , , 




K ' * 


"^ 


"^ 


-ii- 






,03 






1 




i- J 


























t 






'" 




' ' 












, , 






T 


■^ 


y 1 


- '• 




: 




1, 




■ J-' 







— 1 — 




-^^ 


^ , 


, 


-^-- 




Mf^ 


h -, 1 


— 


"^ 


T" 


-r 


























1 




r- 






J 7S70.S7 










gt^c* 




Kxlu 




7t^=«^q. 


i^cpt 






t^pfMtlli, 






1 








8,6.8,6 


?02Citf 


iBieiB 


,bI,3,E 








»2&a 


a,!^ 


.4J.2& 


78240^ 


*2«< 


24^4«'< 




s+TZT+cwicj 


2*a*si 




-™ 




i 


1 1 


















__ 


— 




r,' 1 , 


r 




, 



perha])s non-consouating rales at the bases, would indicate the diagnosis, particularly 
if the patient has inelasticity of the skin of the back of the hands, and has suffered from 
similar attacks for some years past, especially in the winter. The chief difficulty will be 
to determine whether the cause of the cyanosis is pulmonary or cardiac (see below). Lobar 
piiriitnonia as a cause of acute cyanosis is diagnosed chiefly by a history of sudden onset, 
the continuance of pyrexia for a week or ten days and ending by crisis (Fig. 272. p. 642), 
the rapid respiration-rate in proportion to the temperature, the viscid rusty sputum, and 
herpes labialis. Occasionally the pyrexia terminates by lysis or in some other atypical 
way {Fig. 71), instead of by crisis ; or it may rise again after the crisis, particularly 
when empyema follows (Fig. 71). Sometimes the diagnosis is made when no abnor- 
mal physical signs can be detected ; but if over a large portion of a lobe there is at the 
same time impairment of note, with bronchial breathing, bronchophony, pectoriloquy, 
without rales at the height of the malady, but with fine crepitations at the beginning of 
the attack, and with redux crepitations as the bronchial breathing disappears after the 
crisis, the diagnosis will be obvious, especially if during the fever there is a great deficiency 
or complete absence of chlorides from the urine. 

Asthma is sometimes very difficult to distinguish from bronchitis and emphysema, 
because it ultimately gives rise to both the latter (p. 535). It may produce extreme cyanosis 
during an attack. 



CYSTIXUHIA 



161 



Cardiac causes for extreme cyanosis include any of the conditions wliicli lead to chronic 
failure of the right side of the heart. These may be classed into one or other of four main 
groups, namely : primary valvular disease of the heart ; affection of the muscle of the heart 
or pericardium : failure of the heart as the result of chronic lung lesions, especially eni])hy- 
sema, bronchitis, fibroid lung and bronchiectasis ; and cardiac failure when the heart is 
unable to maintain the high blood-pressure due to granular kidney or arteriosclerosis. 
When a late stage in the failure of compensation has been reached, it is often difficult to 
determine whether the primary condition is kidney, heart, lungs, or arteries ; the differential 
diagnosis between these is considered on page 14. 

Cyanosis due to splcnomcgalic polycythccmia (Plate XXIX. p. 634) is slowly progressive, 
and the diagnosis is arrived at by finding in the patient a big spleen with Polycythemia 
(p. 532), and no other very definite lesion. 

Cyanosis due to inspissation of the blood as the result of loss of fluid from the tissues 
in fevers, such as cholera, dysentery, yellow fever or typhus, is a late symptom in a 
disease that will generally have been diagnosed upon other grounds. 

Metha^moglobincemia and sulpli-hcemoglobincemia are diseases which have been grouped 
together under the term enterogenous cyanosis. Both are exceedingly rare. The tint of 
the skin by itself suggests the diagnosis, being altogether different from that of ordinary 
cyanosis, and yet not to be mistaken for pigmentary affections such as Addison's disease, 
argyria, ochronosis, or hsemochromatosis. There is no polycythsemia. The diagnosis is 
established by spectroscopic examination of the patient's blood, a suitably diluted specimen 
exhibiting a well-defined absorption band in the red (Fig. 35, p. 80) in addition to the 
two bands of oxyhtcmoglobin between the D and K lines (Fig. 30. p. 80) : the distinction 
between sulph - haemoglobin and 
methsemoglobin is not easy except 
in the hands of experts in blood 
chemistry and spectroscopy. Some 
cases arise without any obvious 
external cause, and are to be dis- 
tinguished from those in which 
the blood-changes are directly 
attributable to the effect of taking 
chlorate of potash, aniline deriva- 
tives, and possibly otlier drugs. 

llrrbcrl Frcinh. 




CYSTINURIA is the term used 
to (Unolc I III- iircsciicc of cystin 
(CII.^X.SO.J^ in the urine. The 
latter is usuidly pale, turbid, and 
oily in appearance when passed, 
slightly acid in reaction, with an 
aromatic odour resembling sweet- 
briar : after standing, alkaline de- 
composition leads to the formation 
of sulphuretted hydrogen and a 
change in coloin- from yellow to 
green. The cystin forms a light - 
yellowish deposit, which consists of 

colourless microscopic hexagonal jtlalcs (Fig. 72).- The condition is hereditary, and nicrcly 
indicates a peculiarity of mclahollsni. The crystals have occasionally given rise to calculi, 
which are of a light fawn colour when lirst passed or removed, changing to green when they 
arc exposed to the air. Cystin is not dissolved on heating the urine or by adding acetic 
acid, but it is by mineral acids and by annnonia ; from the latter it can be recovered by 
evai)oration : a cIk inical test that has been rec'onuncnded is to boil some urine with 
acetate of lead and caustic potash ; if cystin be present, a dark precipitate should form, 
as the resull ni Ihr lormation of lead sulphide. The best evidence of the condition, how- 
ever, is the (lisc()\(iy "I' llic lypi<'al cr\slals in the urine microscopically. Ihrlurl French. 

i> 11 



162 DEAD FINGERS 

DEAD FINGERS. — Most individuals are familiar with dead fingers arising in ])erfectly 
normal persons -who have spent more than the usual length of time in a swimming bath or 
in the sea ; sometimes all the fingers of both hands will go absolutely white imder these 
circumstances ; e^en the whole hand may go dead-white, but more often it is the fingers 
only. The toes may be affected in a similar way. 

Very similar deadness of the fingers results from exposiue to cold on land, though the 
amount of cold required on shore is much greater than that which produces dead fingers 
in the water. The degree of cold required to produce this deadness of the fingers is much 
greater in the case of some individuals than in that of others, and the more inured the 
individual is, as the result perhaps of his occiii)ation or other circumstances, the less easily 
do his fingers go dead with cold. This being so. it becomes a difficult point to decide just 
where deadness of the fingers ceases to be a jjhysiological phenomenon and begins to be 
evidence of a pathological change. At the other end of the chain one has Rajinaud's disease. 
which is one of the most characteristic of maladies, the patienfs fingers going dead on the 
least exposure to cold, and sometimes often in quite warm weather. This phase of local 
sjTicope often passes on quickly to one of local asphyxia, in which the fingers and generally 
also the toes, from being white, go more or less purjjle or even quite black (Fig. 125, p. 256) 
and remain in this deeply cyanotic state for hours, days, or even weeks, unless artificial 
measui'es are resorted to to restore the circulation. In the most severe cases some portions 
of the affected tissues fail to recover their circulation jiroperly. and die in patches, with the 
result that indolent ulcers develop, healing slowly to form depressed sears, and thus simu- 
lating to a minor extent the effects of fi'ost-bite. Even extensive gangrene and loss of 
fingers results sometimes. 

A \ery similar condition in which dead fingers may be a symiitom results from 
ergotism (p. 259) ; and deadness of the fingers may be one of the phenomena of pellagni 
(p. 225), although here erythema is commoner than acute jiallor. Fortimately both pellagra 
and ergotism are exceedingly rare in this coimtry. 

Between the jjhysiological dead fingers of exposure in cold water or to cold 
atmospheres, and the pathological deadness resulting from Ra^^laud■s disease as the result 
of exposure to temperatures which ought not to cause deadness of the digits in normal 
persons, one meets with varying degrees of precisely similar changes to which it is difFiciilt 
to give an exact name. For instance, an ajsparently healthy individual complains that 
whenever he is getting up on a winter's morning he finds one or other of his fingers, gener- 
ally a -ring or little finger, goes dead and white, and it is not until he comes down 
to breakfast and gets into a warm room with a fire that the circulation becomes restored 
in it : what name is one to give to this ? There is no generalized syncope of all the fingers 
such as one meets with in Raynaud's disease ; and yet the patient suffers from his dead 
fingers without any cause which should be adequate. The complaint is fairly common ; 
generally it is no indication of disease. Four things in particular need to be thought of 
liowcver, before the trouble is put into the category of personal idiosyncrasy, namely : 
(1) Cervical rib ; (2) Aiterioselerosis ; (3) Occupaiion ; (4) Blue-brtiin. 

Deadness of the ring or little fingers may be one of the earliest symptoms in the case 
of a person who has a cervical rib {Fig. 186, p. 443). Later, more generalized neurotic 
symptoms in the arm and hand may be expected, or even atrophy of the nmscles supplied 
from the idnar part of the brachial plexus. Although the rib dates fi-om birth, it is remark- 
able how it often produces no symjitoms until adult life is reached ; it may produce no 
symptoms at all even then ; when it does so the patient's attention is seldom drawn 
directly to the neck, but nearly always to something being the matter with the hand or 
forearm, especially the ulnar aspect of the latter and the little and ring fingers. If one 
realizes that the cervical rib or the fibrous band which joins the end of a buttress cervical 
TihJ^Fig. 187. p. 443) to the first rib, is liable to interfere with the lower trunks of the brachial 
plexus, one can imagine the various vasomotor and other nervous symptoms that may 
result ; and if the possibility occurs to one, the diagnosis is established by means of the 
.r-rays. Only when in place of any bony rib there is but a flbi'ous cord representing it will 
the a-rays fail to show either the entire rib, or more commonly perhaps a stimip representing 
the vertebral end of such a rib, sufficient nevertheless to indicate the cause of the nerve 
symptoms in the hand and arm. 

Arteriosclerosis or atheroma, or both, may involve the vessels supplying the hands 



DEAFNESS 163 

and produce in the latter various symptoms of deficient circulation, including dead finsers. 
The patient will generally be past middle life, and as a rule tlierc will be other indications 
of arterial degeneration, especially raised blood-pressm-e, though when atheroma rather 
than arteriosclerosis is the cause, the arterial affection may be extensive though the blood 
pressure is not raised. The condition in the arms and hands comes on as a rule spasmodic- 
ally, or in paroxysms when the arms and hands are used, and the remarks made on page 
440 in regard to intermittent claudication apply here just as they do in the case of the leg. 
Dead fingers from this cause, however, are not met with frequently. 

Occupation as a cause for dead fingers is familiar in two classes of persons in particular, 
namely first, those whose hands are immersed for many hours a day in waters of different 
temperature, especially if there are chemical ingredients such as carbonate of soda in the 
waters. Dead fingers are in this way one of the troubles which washerwomen are apt 
to suffer from (p. 444). The nature of the patienfs employment may suggest this cause 
if inquiry is made as to exactly how the jjarticular individual carries on his work. The 
other group of persons who are liable to develop dead fingers in one hand or the other as 
the result of their occupation, are those who carry heavy loads upon one shoulder in such 
a way as to depress that shoulder and push the head far over towards the opposite side. 
Apparently what happens is that the pushing asimder as it were of the shoulder and the 
neck throws much strain upon the fibres of the brachial plexus, and in some indi\iduals 
this strain leads to degenerative changes which extend down the nerve of the arm into the 
hand. Pains may be the most prominent result, and these jjuins arc generally most severe 
in the region of the shoulder and the upper arm, esijccially in the parts supplied by the 
circumncx nerve. In other cases, besides the pain, or without pain, muscular atrophy 
results. In a few instances vasomotor phenomena predominate, and dead fingers or even 
a condition similar to that of Raynaud's dis^ease has resulted. That occupation is the 
probable cause will be suggested by the symptoms being so much more pronoimced in 
one han<l than in the other, for it very rarely hajipens that the man will carry weights first 
on one shoulder and then u|)on the other, so as to affect both luaehial ])lexuses alike. 

IShic-hrtiiii is a deserij)tive term, coined by Sir .lames Goodluut to cover a very extensive 
class of ease in which all sorts of peripheral phenomena of a functional type have their root, 
in his opinion, not in a peripheral cause but in a central one ; and as the individuals generally 
have what is called a poor circulation, with a tendency to blueness of the ears and hands, a 
liability to chilblains and oilier phenomena of that kind, he considers that they also have 
a corresponding tendency to poorness of the circulation in the cerebral centres;. Just as 
they have blue extremities, so they have, as he says " blue-brain.' The patients are not 
all women, though the majority are ; they have aches here and jiains there ; the abdominal 
aorta is often unduly pulsatile; the right kidney is often movable; there is suliering at 
the monthly periods ; the knee-jerks are exaggerated ; the patients are of the nervous, 
neurotic, neurasthenic, or even actually hypochondriacal type, .\mongst tlic many symp- 
toms that they may complain of, deadness of the lingers on the slightest proNocation 
may be one ; the condition may then simulate Raynaud's disease, and it is a <iucstion 
whether in Itaynaud's disease itself the vasomotor anomaly is not central rather than 
peripheral* livery practitioner has met with dead fingers in |)atients for whom they can 
recogtii/.e at once that the term ' blue-brain ' fits as an ap])ropriate label ; for a full 
description of the types of case in question he should read Sir .lames (Joodharfs original 
article upon the subject. Ilcrhcrl French. 

DEAFNESS. — This is the most con-.tanl sympldui of disiasc of the ear. It ma\ be 
present in one or both ears, and may vary from a slight dclicicney, \vlii<-li ma\ be 
unnoticed by the patient, to a complete loss of hearing. The causes of dcfci'tive hearing 
arc many. In some cases It can be easily relieved : in others I he prognosis may be abso- 
hilcly hopeless. 

The organ of healing consists iif («(] inMJii pinls. Tlic llisl is a condiieling 
porlinn (■(iiisisliiig uT tin- cNlcriial audil(ii\ nii;iliis. Iyirip:uniiii. iIpmmi. .•mil (issiclis llie 

riiiiili r wliii-li is |<j (■(illcci IJK' sound u:i\(s .iriil Iransniil llii- xibralions lo Ihe 

endolyniph of llic internal car. The second porlido conlains Ilie l.-ihyrinlli (■(lelilea, 
vestibule, and semicircular <'anals in which arc silualcd Ihe lerininalidiis cil Ihe auclilni\ 
nerve, De^d'ness may be caused by a lesion either of the conducting port ion of the audilory 



164 



DEAFNESS 



apparatus, or of the internal ear, wliich contains the receptive mechanism. The latter — 
labyrinthine or nerve deafness — is tlie more serious and visually the more severe, but the 
former is much the commoner. Rarely, deafness may be due to some disease of the 
auditory nerve or to some tumour of the brain involving the fibres of the nerve in their 
intracerebral course. 

Tests for Hearing. — In the examination of a deaf patient, a careful investigation 
of the sense of hearing is necessary : (a) To estimate the severity of the deafness ; {b) Tn 
ascertain whether the lesion is situated in the conducting apparatus, or in the labyrintli 
or auditory nerve. Before carrying out these tests it is well to examine the external 
auditory meatus with a speculum, to make sure that the deafness is not due to the presence 
of a plug of cerumen, in which case elaborate hearing tests are unnecessary. The following 
are the tests usually applied : — 

1. The Whispered Voice Test. — This consists in noting the distance at which whispered 
words are heard. Vowel sounds are usually heard better than consonants. The examine)- 
must cultivate a whisper of uniform intensity, and the patient's eyes should be covered 

to avoid the possibility of ' lip reading.' Each ear 
must be tested separately, the other external audi- 
tory meatus being covered by a finger. 

2. The Watch Test. — Here the distance is 

measured at which the ticking of a watch is heard. 

The same precautions must be taken as in the 

\oice test. The observer must first measure the 

distance at which it can be heard by a normal 

person. Suppose this to be 30 in., and the pnticnt 

Iiears it at a distance of 12 in ; 

the patient's hearing is then 

described as 1 j;. Instead of a i lli 

watch, Politzer's acoimieter {Fig. 

73), an instrument producing a 

Fu/. 73.— Politzer's acoumetei. uniform tapping sound, may be 

used. 

The results obtained by these tests by no means always coincide. 

Sometimes the whispered voice may be heard remarkably well wliile the 

watch is almost inaudible. This is more likely to be the case when the 

onset of the deafness is late in life. More rarely the watch is heard 

more easily than the voice. 

3. Tuning-fork Tests are of the greatest importance, since it is chiefly 
by these that labyrinthine or nerve deafness can be distinguished from 
deafness due to a lesion of the external or middle ear. In the latter 
case tlie sound waves are obstructed on their way to the receptive 
apparatus, and cannot be heard when the fork is near to, but not in 
contact with, the ear ; whilst if the base of the fork is applied to the 
mastoid process, forehead, or chin, the vibrations are heard readily, 
because they are now conveyed to the normal receptive mechanism 
directly through the bone. In nerve or labyrinthine deafness, on the 
other hand, though the vibrations are transmitted by the bone, the sound is heard poorly 
or not at all, for the receptive apparatus is at fault, and is unable to respond properly 
to the stimulus of the soimd waves, whether they reach it viii the external and middle ear, 
or through the bone. 

The tuning-fork used should be one which \ibrates 256 times per second (C). It 
should have a flat foot-piece (Fig. 74), so that it can be applied conveniently to the bone, 
and it may with advantage be fitted with a contrivance to prevent the occurrence of over- 
tones. In addition, tuning-forks vibrating 64 times per second and 1024 times per second 
should be at hand, for testing the perception for high and low tones. In an elaborate 
investigation, still higher pitched timing-forks may be necessary. The following are special 
tests used in testing bone conduction in a deaf patient : — 

1. Rimie's Test. — The tuning-fork is struck lightly, and the flat foot-^jiece is held 
steadily against the mastoid process. Directly the patient ceases to hear the sound, he 





DEAFNESS 3 65 

raises his hand, and the fork is then held close to the external auditory meatus. If tlie 
sound is heard again, the result is positive : if it is inaudible, the result is negative. The 
test may also be carried out by holding the fork opposite the external auditory meatus 
first, and then, when it is no longer audible, apjilying it to the mastoid. A useful modifica- 
tion of this test is for the examiner to wait until the fork is no longer heard by the patient 
tln-dugh the mastoid, and then to transfer it to his own mastoid. In this way the bone 
conduction of the patient is compai'ed with the bone conduction ot a normal individual. 

2. IVebefs Test. — This is especially useful in unilateral deafness. The vibrating fork 
is a]>plied by the flat foot-piece to the middle of the forehead. The patient is then asked 
in which car the sound is heard best. If the deafness is in the external or middle car. the 
sound will be best heard on the deaf side (positive) ; if due to a lesion of the internal ear 
or auditory nerve, it will be heard in the good ear (negative). Great care has to be exercised 
in this test to get the correct reply from the patient, as there is often unwillingness to 
admit hearing in the affected ear. 

3. GelWs Test. — The air-pressure is increased in the external auditory meatus by 
means of a Siegle"s speculum. The vibrating fork is then applied to the mastoid, or to 
the middle of the forehead. In a normal person, bone conduction is diminished. ^Vhcn 
it is unaffected it is generally considered that the foot of the stapes is lixed. 

The hearing of liigh or low tones is ascer- 
tained by using tuning-forks of a rapid or low 
rate of vibration. Galton's whistle (Fig. 7.">), 
which produces very high notes, is also used for 
this purpose. By means of this instrument a 
note as high as 50.000 vibrations per second 
can be produced. If notes of more than 20,000 
or 2.5.000 vibrations are not heard, the auditory 
ncr\e is probably affected. -f'!'- '5-Galtous «l.i=tlc. 

To sum up, labyrinthine deafness is indi- 
cated when l)onc conduction is diminislied markedly, i.e.. when Rinne's test is positive and 
Weber's is negative. (Jenerally speaking, in this form of deafness the perception of high- 
pitihed sounds is diminished. It must, however, be remembered that in old people the per- 
ception of high notes is generally diminished considerably without any affection of the nerve. 

Deafness due to some error in the conducting ajjjjaratus is indicated when bone con- 
duction is good, i.e., when Rinne's test is negative and \Vel)(r's jxisitive. There is also 
likely to be [loor perception of low-pitched notes. 

In carrying out these tests, however, it must be remembered that, in a patient over 
fifty, bone cotidiietion is nornially diininislied. so tiial llic lists are olten inconeiusixe in 
an elderly pali<iit. 

Deafness due to a Lesion ot the Sound-conducting Apparatus. — When lliis is 
the case, eilher the external or the middle ear may I)e at fnull. i^xamination with the 
speculum will readily reveal the presence of a jiliiil of venniiiti. /joln/ii. or a ftirciiiii '""'.'/i 
.such as a mass of wool, which is not inlii'(|uent!\' inserted and forgotten by the palienl. 

The cihise of middle-ear deafness will be <liagnosed by considering otiur syin|)toms 
which may be jirescnt, such as pain and tinnitus, together with an examination of the 
tympanic metubrane. and of the nose and naso-|)harvnx. Deafness is more or less marked 
in all iii/liiniDuildn/ ilisrti.trs of the miildle cur. acute or chronic. sK/i/iiiriitive or noii-sii/>i>iiriitirc. 
It nuisl be reniemberi'd that there is not necessarily a correspondence between the intensity 
of the deafness and tlu- condition of the iTiembrane. The latter may be destroyed and 
hearing may remain fairly good, while with a small perforation, or in chronic non-suppurative 
otitis mi'dia. with but little alteralioii in llie appearance of the membrane, the deafness 
niiiy be profound. 

Ctit/irrh of the Eiixtocliioii tiilic. iir ubsliucliini lo Iliis passage l)\ the |inMiice lA' uilcnoiils 
or iiiliir!>cil tonsils, is a e(itiiiiion cause of dealtiess. especially in eliildren. 

In Mime eases iif iMiddle-car deafness, especially in otosclerosis, where llie lnul -plale of 
llie stapes is lixed. (he patient may hear ordinars speech belter in a noisy place Ihan in a 
i|niel idiiMi. This is known as paracusis U'illisii. It is generally cNpliiiiied by supposing 
Ihal the more ext<'nsive vibrations caused by the loud noise loos<ii Ihe juiiils belween the 
ossicles, whieli are ollu'rwise abiioriiiallv slitl. 



166 DEAFNESS 

In disease of the ooiiductinii apparatus, the patient, though deaf, not infrequently 
hears liis own voice very loudly, and also noises in the nasopharynx such as occur on 
swallowing. This is known as aiitoplionia. 

Hypencstliesia aciiniica is a term a})])lied when sounds produce an act\ial j^ainful sensa- 
tion in the ear. It may be present in acute inflannnation of the middle ear. fevers, and 
migraine. 

Nerve or Labyrinthine Deafness may be due to a lesion of the auditory nerve itself, 
which may be invohcd in a iiniivth of the temporal bone, or may show degenerative 
changes in tabes. It may also residt from a definite intracranial lesion such as a tumour 
of the mid-brain or pons. A diagnosis in these cases will be made from the coexistence of 
other nervous symptoms associated with cerebral tumour. In labyrinthine deafness the 
following actual pathological changes have been found : (1) Degenerative changes in the 
organ of Corti ; (2) Hnemorrhage ; (3) Organized inflammatory jirodiicts ; (4) Rise in 
pressure in the endolymph. 

The following are the chief causes of labyrinthine deafness : — 

1. Extension from disease of the middle ear. suppurative (pyo-labyrinthitis) or non- 
sup])urative (occasionally in otosclerosis). 

2. Apoplectic deafness or Meniere's disease, which may be due to ha-niorrhage or a 
sudden rise of intracranial pressure. 

3. Following the specific infectious fevers, especially numi|)s, but also influenza, 
typhoid, measles, scarlet fever, and others. 

4. Syphilis. In the acquired disease, deafness may occur at almost any stage. The 
onset is usually sudden, the trouble is usually unilateral, and may have all the characters 
of Meniere's disease. In congenital syphilis the deafness usually begins between the ninth 
and sixteenth years. Eustachian obstruction and retracted membranes are frequently 
present, but the deafness progresses and is labyrinthine in character. Other signs of 
congenital sy])hilis will be present to assist in the diagnosis. 

Deafness may follow an injection of .talvarsan. It may appear after an interval of 
se^■cral days, or as long as three months. The short interval is usually after an intravenous 
injection, the longer when the drug has been injected into the muscles. The deafness is 
more or less absolute and has the characters of nerve deafness. By some this is regarded 
as due to the drug ; others regard the lesion as due to the liberation of a large quantity 
of endotoxin consequent upon the destruction of the spirochaetes. 

.5. In Uright's disease, leukfemia, pernicious and other anaemias. A luemorrhage is 
fre(iuently the cause of the trouble here. 

0. Certain drugs cause transient deafness of labyrinthine character ; notably quinine. 
and sodium salicylate: possibly alcohol and tobacco. Mercury and lead also are stated 
to cause deafness sometimes. 

7. Traumatic. Labyrinthine deafness may follow blows, falls, or fracture of the base 
of the skull. 

8. Occui)ations, such as caisson workers, or workers in a continuous loud noise (boiler- 
makers' deafness). 

9. Meningitis, especially cerebrospinal meningitis ; and occasionally in epilepsy. 
Deafness may also occur in hysterical individuals. This may usually be recognized 

by the manner and aspect of the patient, and by the absence of abnormal physical signs 
on examination. 

Lastly, it must be remembered that deafness may be complained of by a malingerer : 
the fraud is usually exposed by contradictory replies to hearing tests with the eyes bandaged, 
or by speaking into the chest-piece of a binaural stethoscope with the tube to the sound 
ear plugged with wool. The probability is that the patient will say he hears words sjioken 
into the stethoscope, but on removing this and covering the sound car with the finger, he 
will say that he hears nothing. Philip Turner. 

DEFORMITY OF THE CHEST.— In the differential diagnosis of alterations in the 
form of the chest, it nuist be remembered that many slight deviations from its typical 
form are not produced by disease. A long narrow chest {alar ehest), or one flattened 
anteriorly (flat ehest) is often found in ])ersons predisposed to phthisis : but these also occur 
in individuals who are ne\ev affected by this disease. A long neck and sloping shoidders 



DEFORMITY OF THE CHEST 



167 



are also associated with tliis coiulitioii. while a short, tliiek neel; with hiuh shoulders is 
found in persons subject to apoplexy. The alterations in the form of the chest which may 
result from disease may be considered luider the following headings : — 

(1). Deformities the result of rickets ; 

(2). General ehnnges in the form of the chest : («) Tlic barrel-shaped, (b) I'nilateral 
enlargement, (e) Unilateral shrinking ; 

(3). Local changes : {a) Bulging, (b) Retraction. 

Rickets. — The following deformities of the chest in an infant are due to rickets : — 
Tlie chest is somewhat pear-shaped on transverse section, and a long vertical groove 
is often seen on each side of the sternum. Beading of the sternal ends of the ribs 
takes place, giving rise to the rickety rosary. The pigeon chest, in which the ribs are 
flattened on each side in front, so tliat the sternum becomes unusually prominent, making 
the chest appear somewhat triangular on transverse section, is always due to rickets 
(Fig. 78). Harrison's salens, a liorizontal groove in the lower part of the rickety chest, is 
due to tlie sinking in of the ribs above the attachment of the diaphragm. This groove is 



/ 2/* 


z!^^ j 


\ 


fo^- /, 


\\ 


10 /' 


\ 


A 


\l 


iiy 




f Z^A 


z%\ 




S: Jl 


\\ 


10 // 


^^ 


y^' 



/^'"'"^ 


r— =-c^ 


(' 5 '/z ; 


4% \ 


i \ 




X^.. i 


^'''' 




-l-'ibiosis of the left luiu 



—mail, ased 30 years. Fiij. SO. -Emphysematous 

CVKTO.METRIO TKACINGS OP VARIOUS FORMS OP ClIKST. 



Traiisvei-sc sections ot various forms ol chest at the level of the stcnio-xiphoid 
cyrtometric triuMiii.'s. 'I'lie dotted lines indicate the natural shajie .at the same iigc. 
' I iiiclies. (Sawyer's Physical Signs, 1908.) 



exaggerated because the lower ribs are pushed out by the increase in size of the abdominal 
viscera. .Ml these deformities are associated with other signs of rickets in the cliild. 
which make the diagnosis easy. 

General Changes. — (a). The Barrel-shaped Chest is Idiinil in palieiits suffering 
from palaionarij cnijilii/sema {Fig. 80). The chest is enlarged In all dircclions and gives 
the appearance which is assinned by the normal chest only after deep ins|)iration. The 
antero-postcrinr diameter is greatly increased. The shoulders arc higher and squarer 
than in heallh, Ihc inlercoslal spaces are enlarged and bulging, the dorsal cm-vc of the spine 
exaggerated. 'I'lic mo\cmenls of Ihc chest during respiralion arc extremely restricted ; 
there is elevation of the chest as a whole during inspiration, but very little real expansion. 
The neck a|)pears abnormally short. The apex beat of the heart cannot be I'elt. On 
percussion the note over the limgs is liyper-rcsonant, the cardiac dullness is greatly dim- 
inished and often obliterated, and the upper level of the hepatic dullness is lowered. Tin- 
breath-sounds upon auscultation arc eiilccbled. and expiration is markedly prolongcil. 
If bronchitis be |ircsciil alsd, advcnl ilious sounds arc heard. espcci;dl\- sonorous and siliilaiil 
rlioiiclii aoil i-niiisc hiilililini; talcs. Tlic licarl-MHiuds iiif dlHictdl In hear. 



168 DEFOKMITV OF THE CHEST 

Wheuevev any loss of symmetry in the two sides of tlie chest is found, the vertebral 
column must be examined carefully, as the alteration may be due to spinal curvature. 

(b). A Unilateral Enlargement of the chest can be produced by an extensive pleuiitic 
effusion, a large empyema, pnenmothorax, and when an intrathoracic tumour affects the greater 
part of one side of the chest. The cause of the enlargement is ascertained by tlie physical 
examination ; thus with pleuritic effusion, either serous or purulent, the movements of 
the affected side during respiration are restricted, while those of the opposite side are exag- 
gerated : dullness is foiuid over the effusion, while above it the note is usually of higher 
pitch than normal, and often skodaic ; vocal fremitus, breath-sounds and voice-sounds are 
diminished or absent over the dull area. At the upper level of the fluid asgophony may be 
present, and the breath-sounds frequently tubular. The presence of ihiid is further con- 
firmed by finding the heart pushed over to the opposite side, and the liver depressed when 
the right pleura is involved. When a pneumotlwrax is present, there is usually a history of 
a sudden onset, accompanied by a severe pain in the chest ; the affected side does not move 
as freely as the other with respiration ; the heart is displaced towards the opposite side, 
and vocal fremitus, breath-, and voice-sounds are diminished or absent, though the affected 
side of the chest is fully resonant : if serum or pus be jsresent in addition to air, the 
note is dull or greatly impaired at the base of the lung, with hyper-resonance but absence 
of breath-sounds above. When much fluid is j)resent. the note changes considerably with 
the position of the patient. The metallic tinkling of Laennec is sometimes heard over a 
pneumothorax ; coughing is generally required for its production ; it resembles the sound 
which occurs when " a drop of water falls on the sin-face of a fluid contained in a lialf-fllled 
decanter." The bell sound or " bruit d'airain " is very characteristic of a pneumothorax ; 
to hear it, auscultation is performed over a portion of the pneumothorax, and a coin placed 
on another portion is struck with a second coin ; the sound has a ringing metallic quality 
like that of the tinkling of a small bell, or like the ring that accompanies hammering upon a 
blacksmith's anvil. Hippocratic succussion may also be obtained when the observer's ear 
is applied to the chest while the patient's body is shaken or jolted. 

(c). Shrinliing of tlie tvhole of one side of the chest is due to contraction of one lung, 
either as the result of a ))revious compression by a large pleuritic effusion, and especially 
by an empyema, or on account oi fibrosis of the lung (Fig. 70). The history of the patient 
often indicates the cause of the contraction of the lung ; a large effusion may have been 
aspirated, or an empyema may have been drained by surgical means, leaving the scar of 
the operation. In other cases the empyema may have burst into the lung, and there may 
be a history of a large amount of pus having been expectorated. With fibrosis of the lung 
the affected side is retracted and .shrunken, the intercostal spaces are very narrow, and 
the ribs may even overlap. The shoulder is lower on the affected side, and the vertebral 
column is deviated towards the diseased lung. The heart is drawn over to the affected 
side, in which there is very little movement during respiration. If the left lung be affected, 
the heart will be less covered by lung than normally, and so there may be a large area over 
which cardiac pulsation is visible. The note over the contracted lung is impaired, while 
on the opposite side it is hyper- resonant. The breath-sounds are deficient or absent, and 
may be tubular or cavernous, while at the base there may be numerous coarse bubbling 
rales, especially if there is bronchiectasis. Vocal fremitus may be decreased or exaggerated. 
The expectoration is generally copious, semi-purulent, and often fa?tid. There is often 
marked clubbing of the tips of the fingers. 

Local Changes. — («) The cause of bulging of any portion of the chest wall may be 
dilficult of diagnosis, though sometimes it is obvious, as when an empyema points externally ; 
even this is sometimes mistaken for a localized abscess of the chest wall, unless a careful 
examination reveals the sign of fluid within the chest. In pulmonary emphysema, bulging 
is often present in the supraclavicular and infraclavicular regions. Bulging may also be 
due to an intrathoracic tumour, to an aneurysm of the aorta, or to a tumour or abscess of the 
chest wall. The most common situation on the chest wall for an aneurysmal swelling is 
to the right of the sternum in the first, second, and third intercostal spaces ; it may erode 
the upper part of the sternum and so produce a swelling there, while in rare instances it 
may produce a prominence to the left of the sternum : a bulging to the left of the vertebral 
column may be due to an aneurysm of the descending thoracic aorta. The expansile 
character of the pulsation suggests the diagnosis. A tumour or abscess of the chest wall 



DELIRIUM 169 

may occur in any situation. The pra^cordia l)ecomcs ])rominent in children in cases of 
pcricardinl effusion, or wlien tlie heart is enlarged : the situation of the prominence 
indicates its cardiac orioin. An enlargement of the liver (p. 366) may also produce a promi- 
nence of the ribs under which it lies ; a hepatic abscess, a subdiaphragmatic abscess, or 
an empyema, sometimes point over the lower part of the chest in front, while a psoas 
abscess may point over the lower ribs posteriorly. A prominence over the s])inal column 
in the dorsal region may be due to spinal earies, or to a malignant were growth of the spine. 
An angular curvature of the spine is most commonly due to spinal caries, and any swell- 
ing which is associated with it may be produced by an abscess arising from the disease. 
Bulgings which give an impulse on coughing, and which wax and wane with respiration, 
suggest hernia of the lung, sometimes of considerable size in marasmic children suffering 
from whooj)ing-cough. or in emaciated phthisical subjects with incessant cough. 

(6). lietraction or localized shrinking of the chest wall occurs in any condition in which 
there is a portion of hmg contracted by disease. When present over one or both apices 
of the hmgs, as shown by retraction in the supra- and infraclavicular regions, it is nearly 
always due to phthisis. Unilateral shrinkage is also found with fibroid eonditions of the 
lungs which are not tuberculous, or alter the absorption of a pleuritic effusion or the 
removal of the pus from an empyema. J. /■;. //. Sawyer 

DELIRIUM occurs in an overwhelmingly large proportion of cases in the course of 
some well-known disease, commonly pyrcxial. and beyond the fact that the condition 
itself in such diseases is a symptom of somewhat serious import, nothing need be said as 
regards the diagjiosis. There arc, however, a few prognostic points worthy of mention 
in connection with such cases. Thus, in typhoid during the height of the fever, in measles, 
and in scarlet fever, the delirium is eonuiionly in ])roportion to the pyrexia in its violence, 
aiKJ can usually be controlled by controlling the pyrexia, if necessary : in the later stages 
of (yphoid, a low mutUring delirium is of very serious import. In pneumonia, on the 
other hand, .some degree of delirium is an almost constant factor, no matter what the 
temperature may be, and its significance depends upon the previous (alcoholic) history of 
the patient, u|)on the violence or .severity, and duration or persistence of the mental 
phenomena. In rheumatic fever (unless due to salicylates, vide infra) delirium is of 
extreniely grave signilicanee. being commonly associatcfl either with hyperpyrexia or with 
dclinilc iiil racranial inlliunmation. neitlKr of which is at all ((iiiinHiii. In iiiMiienza, too, 
it is a sym|)tom causing great anxiety. 

'I'he flilliculties of diagnosis arise chiefly when wc arc cnllcd to a case of delirium of 
wliiih we have no previous knowledge, where in fact our sirv ices arc sought ])rimarily 
because the ])aticnt lias " gone off Iiis head and is talking nonsense." and we must consider 
to what <lilferent factors this may In- due Tlir following table embraces causes ordinarily 
met with : 

Delirium iliic In iiitiiiisic l)niiii- ( Mania or huiaey in all its forms 

(•ell elianycN or to pure lurvc I'ain. oecasionaily so severe as Id prnil ice it 

inllia-nccs I .SIkicU, ilillo 

I , I- . * . . I I r.rmia 

'":'"■';,"";'";■ '■' l-;"-"" •"'^'"i^ nial.etes. .\,u-mia. l'»lv.vtli;.„,iM? 

'" ""■ ^ (autogenetie) , ,,„,,,.„,,i„j, ,,,.,„|, |,,„„ ,,„,. ,.,,„,;.. 

Diliriiiiii due 111 mil idhieaetivi- * Fevers of any kind, known ;iii(l imUiiown ms In llicir 
lies I specific niicrobie origin 

l' Helladonna, hyoscyanms, and llicir allies; mIcoIihI 

;ind other less eiinimon iiiloxicMiits, :iii;esl li<l i/.iiifi 

DiliriiiTM due 1 1 1 iliciiiiinl ^ifriiils I Mibsl anccs, :iiid liypiiolies. Lead, and iillicr milals 

inlrddiiccd rniiti williniil i (i((a>i(iMaily . l'',X((|)li<)nally, II arises rrcim almosl 

liny i)()ison or drug, most lypicidh , pcrliiips. IViitii 

' iiriilieiul salicylate of sodium. 

As with all oth<-r tables of diagnostic i)roblcms, the difliculties are much greater on 
paper than in praetiee. for in almost e\ery case there is some one overwhelming and out- 
st;in(ling lact in the history which settles the matter olf-liand. It is well, however, to 
lia\e some lixed order (d' procedure laid down, which may take the following lines : - 

I. Make strict iniiuiries as to anything umisual having been taken or applied lately. 



170 DKLIRIl^r 

Medicines containing belladonna, drops ])ut into the eyes, or some strange or unusual 
vegetable eaten, are the most likely things. 

2. Enquire as to the recent health of the individual bearing on the urinary secretion, 
amcmia, etc. ; also enquire about incidents that might have caused shock, and incidents 
suggestive of a simple idiopathic mental disorder. 

3. Take the temperature ; if materially raised it suggests some form of niicrobie 
iuduence. although in some, such as rabies, the pyrexia may not be great. 

4. Note the pupils ; if dilated and fixed, they suggest belladonna or perhaps 
alcohol — deliriiun tremens can hardly occur without a definite history of " soaking,' or 
an accident ; contracted and immovable pupils suggest urajmia ; unequal pupils, general 
paralysis of the insane. 

5. Test the urine : this will go far in clearing up lu'inary causes. Further details 
must be sought under the appropriate headings. 

6. Note the skin, whether dry or sweating, wliether flushed or pale ; in poisoning by 
belladonna, etc., it is often dry and flushed ; if connected with other dangerous chemical 
poisons, it is commonly pale and sweaty. Fred. J. Smith. 

DIACETURIA — or the passage of diacetic acid in the urine — occurs under precisely 
similar cin iiinstanees to Acetoni'RI.v (p. 3). The following is the usual clinical test 
for diacetic acid : — Tt) one inch of urine in a test-tube add li(iU()r ferri perehloridi (B.P.) 
drop by drop. For a moment a white ])recipitate of iron phosphate forms, and then, if 
accto-acetic acid be present, the liquid becomes deep purple-red, this colour being dis- 
charged on warming. If carbolic acid, salol, or salicylates are being taken, the urine 
contains jjhenyl compounds which give a similar reaction with ferric chloride, but the 
colour due to these does not disappear on warming. Herbert Frciirli. 

DIARRH(EA. — It is important to remember that diarrhoea is a symptom and not a 
disease in itself, and in every case one must try to discover what the underlying cause 
of the looseness of the bowels is. In order to do this it may be necessary, in addition to 
routine physical examination in the ordinary way, to employ one or all of the following 
special methods : (1) Digital examination of the rectum ; (2) Inspection of the lower 
colon by the sigmoidoscope ; (3) Investigation of gastric digestion by test meals (see p. 
319) ; (4) Examination of the stools by the naked eye and by the microscope. Most of 
these methods require no special description, or have been dealt with in other articles, 
but some account must be given of the examination of the stools. 

Various ' test-diets ' for the investigation of the intestinal functions have been proposed, hut 
it is sufficient to let the patient include the following articles in the dietary for about forty-eight 
liours before the stool is examined, viz : (1) IMilk ; (2) Eggs ; (3) Meat in some form ; (4) Farin- 
aceous foods, e.g., bread, potatoes, rice ; (5) Green vegetables and stewed fruit ; (6) Fats, e.g., 
butter, bacon, fat, ham, etc. The choice and amoimt of the individual articles may be left to the 
patient's taste. 

In order to examine the stool, a portion the size of a walnut should be rubbed up with normal 
saline solution to a fluid consistency, and examined with the naked eye against a dark background. 
Normally one sees a homogeneous fluid made up of very small dark-grey particles. In pathological 
conditions one may recognize mucus, pus, blood, parasites, the remains of connective tissue in the 
form of yellowish-white shreds, brown muscle fibres, and the residue of potatoes in the form of 
glossy granules. 

For microscopical examination one prepares three specimens. The first is examined as it is ; 
to the second one adds a few drops of 30 per cent acetic acid, and heats a little to dissolve fat ; to 
the third is added a little iodine solution. 

A normal stool shows in the first pre])aration a few muscle fibres, some yellow lumps of lime 
salts, and a few empty jtotato cells. In the secoud iirrparatiou, a few fatty crystals : in the third 
a very few violet-tinted .starch grains. In i)allioln;jiial couditinns one may "find in the first prepara- 
tion many well-preserved muscle fibres, nuuK mus l:il (hdplets and fatty crystals, and abundance 
of potato cells ; in the acetic acid preparation, niiiut nnis masses of crystals of fatty acids ; in the 
iodine |)rc])aration, an excess of starch. 

In order to test for Bile, mix some of the stool with concentrated corrosive sidjlimate solution 
and allow to stand for twenty-foiir hours. Normally it turns red from the presence of urobilin ; 
greenish ]iailicks show the presence of unaltered bilirubin ; absence of green or red colouring 
shows thai MIc is not present at all. 

licacliun of the Stool. — A drop of the stool prepared as above by rubbing up with water is 
applied with a glass rod to a piece of moistened litmus paper. The reaction can easily be seen on 
the other side of the paper. .\ normal stool is nearly neutral ; marked alkalinity indicates putre- 
faction ; acidity sliows carbohy<lrate fermentation. 



DIARRHCEA 171 

Test for " Ociull ' Blood. — The patient must have eaten no red meat for two or three days. 
A portion of tlie stool the size of a hazel-nut is rubbed up with 2 e.e. of distilled water in a mortar 
and plaeed in a test tube. Add half its volume of glacial acetic acid, and shake. Then nearly 
lill the tube with ether, and reverse several times. To about one inch of the resulting yellow. 
translucent, ethereal solution, add : (n) a few drops of glacial acetic acid, (6) one inch o( frculili/ 
jiri'/Kireil KiUtratcd solution of benzidin in rectified s|)irit, (r) one inch of liq. hydrog. perox. Shake, 
and pour a few drops (jti tn a porcchiin slab. If blood be |)resciit, a blue colour appears. 

diarkholA in infancy and early childhood. 

1. Acute. — Tlie acute diarrhoeas of infancy are either dyspeptic or infecti ve in ofigiu. 
Tlie infective diarrlioeas are usually spoken of as ' summer ' or " epidemic ' diarrhoea. It 
is often impossible to distinguish sharply between the simple dyspeptic and the infective 
variety, but it may be said that the greater the signs of toxaemia (collapse, sinking in of the 
foutanclle. inelasticity of the skin, etc.) the more likely is it that the case is one of infection. 
High body tcmijcrature and epidemic prevalence of the disease are also in favour of such 
a diagnosis. Dyspeptic diarrhoea may be due to mal-digestion of any of the constituents 
of milk. Kxamination of the stools may enable one to distinguish which constituent is 
at fault, thus : — 

Stools containing white tough particles, insoluble in alcohol and ether mixture = 
casein indigestion. 

tJrccn slimy stools containing small granular masses soluble in alcohol and ether 
mixture = fat indigestion. 

Frothy sour stools = sugar indigestion. 

(irecn stools arc of no special diagnostic value, as they merely indicate that the 
contents have been hurried unduly through the intestine. 

If the stools C(mtain visible blood and mucus, and are passed with much pain and 
straining, ticiile colilis may be diagnosed, but not until inlussiiscepiion has been excluded 
(see Blood pkk Anum, p. 75). 

2. Chronic. — Chronic diarrha-a in infancy may follow upon an acute infective diarrhica 
or be dyspeptic from the outset. The history and a consideration of the ])oints mentioned 
above will dctcrinine the diagnosis in most cases, but it must be rcniembcrcd (1) That an 
intestinal catarrh set up by an infcctioTi may lea<l to mal-digestion and ])ersistent chronic 
diarrhoea in consciiuence ; and (2) That a dyspeptic diarrlujea predisposes to the develop- 
ment of intestinal infections. The two classes may therefore pass into each other and 
an exact dilTcrcntial fliagnosis be impossible. 

There is a, special form of chronic diarrlicca in early lil'r which follows a very prolongeil 
course, and to which the term ' cucliac disease " or " the caliac affection ' is applied. 11 
usually starts in the .second or third year of life, and is eharactcrincd by the passage of 
stools which are not very frequent but are bulky, pale, and extremely offensive, containing 
much undigested lal and free fatty acids. The abdomen is tumid and tympanitic, and the 
child wasted and sliinhd in growth and dcNclopment. 'I'liis form of diarrhtra is very 
apt to simulate abdominal hibcrculosis. and indeed is usually diagnosed as such ; but in 
abdominal luliirc iilosis cidargeil glands or a rollcd-up and thickened omentum can usually 
be felt, or, there is ascites or evidence (i( tui)crculosis elsewhere. .Sometimes, however, a 
diagnosis is only possible after watching the ])rogrcss of the case. If the stools in a ease of 
chronic diarrhoa contain visible mucus and blood, and are passed with inucli sirainirig, 
sju'cial involveineril of Ihe large bowel ma\ be diagnosed (chronic colitis). The hislory 
will usually i)oint lo llie preeeiling oe( urreriee of an attack of acute colitis. 

DIARRHtEA IN ADULTS. 

1. Acute. The hislory is of gical iniporlaiiee. II may elicit some iiitliscrclioii of 
(lid (the eating of unripe fruit, etc.), or the consumption of some toxic article of food 
(pUniKiiiic /xiinoiihif') or irritant drug (e.g., arsenic). In such cases vomiting is often i)resenl 
as well. In toxic cases there is great depression, and a feeble aiul, perhaps, irregular pulse. 
If there be fever, oiu^ should lhiid< of an iid'eeli\e cause, such as typhoid fever, or dyscnicry. 
In Ihe case of Ifijihoiil. enlargeiiieni of Ihe spleen is an early coidirnnitory sign, bul is some- 
liiMis alisiril : spols sliouid also !)<■ looked foi'. The presence of leucopcnia may be of 
help, anil Ilie pnls(-ralc is Ion in propiiilion lo Ihe temperature. The agghitinal ion 
naelioii is iiol nsiially olil a ioalile onlil liic rn.l nl lli>' lirsl week. In (///.sr/i/e/// Ihere will 



17.2 DIAP.KHCEA 

be teuesinus, with blood and mucus in the motions. In the amoebic form, the Amoeba colt 
may be found in the stools (see Fig. 25, p. 77). In the specific form, the blood senmi 
agglutinates Shiga's bacillus. Similar symptoms to those of dysentery are produced by 
acute colitis, especially of the ulcerative form. 

Appendicitis may begin with acute diarrlui-a, and the possibility of this should be 
borne in mind. 

In })ernicious aiiceniia, cxoplithalmic goitre, and Addison's disease, periodic attacks of 
acute diarrhoea are apt to occur. The other characteristic signs and symptoms of these 
affections will be present. (See AN.a;MiA, p. 24: and Pigmentation of the Skin, p. 
528). 

Finally, it should be remembered that even although diarrhcea is due to a new growth 
in tlie bowel, it may begin acutely, and a rectal examination should never be omitted. 

2. Chronic. — Chronic diarrlifi-a in the adult may be the residt of several causes, of 
wliieli tlie following are the chief : — 

Impaired Gastric Digestion (gastrogenic diarrhtea). — The looseness tends to occur in 
Ijouts, with intervals of freedom. The stools contain fragments of connective tissue and 
show inidcr tlie microscope an excess of unaltered muscle fibres. A test meal reveals 
absence or great diminution of gastric juice (achylia). 

Impaired Pancreatic Digestion (pancreatic diarrhoea). — The stools are pale or white 
in colour, very offensive, and show, on cooling, solidified fat masses ; microscopically they 
exiiibit excess of fat globules and fatty acid crystals along with undigested muscle fibres 
and starch granules. 

Local Conditions in the Colon : — 

(a). Fcecal Impaction (])aradoxical diarrliu*a). — This variety is commonest in elderly 
persons. Rectal examination reveals retained faeces, and faecal masses may perliaps be 
felt through the abdominal wall. A thorough evacuation arrests the discharges. 

(6). Neiv Growth. — There is nothing absolutely characteristic about this form of diar- 
rhoea, but the motions are often explosive and tend to occur in the early morning. Blood 
may be present in the stools, but not always. Digital examination of the rectum or the 
use of the sigmoidoscope will reveal a growth. It should be noted specially that neither 
a sudden beginning of the symptoms nor the youth of the patient excludes the possibility 
of growth. 

(f). Chronic Catarrh of the Colon or Rectum. — The diarrhoea in this variety tends to 
be ill the early part of tlie day ("morning diarrhoea'), the stools are well-digested and 
may or may not show visible mucus. Examination with the sigmoidoscope will show a 
catarrhal condition of the mucous membrane if the disease affects the pelvic colon. In 
cases in which the chief seat of the affection is higlier up, it may only be possible to arrive 
at a diagnosis by the method of exclusion. 

(d). Ulcerative Colitis. — The stools are frequent, usually small, often passed with some 
straining, and contain visible mucus, blood, and shreds. The sigmoidoscope reveals ulcera- 
tion of the mucous membrane. The ulceration may be dysenteric or non-dysenteric in 
nature. l)ut tlie history will usually enable one to make the distinction. 

Catarrh of the Small Intestine. — The stools are usually copious, fluid, free from visible 
nuieus or blood, unless the colon be involved as well, and show under the microscope 
impaired digestion of all the food constituents and the presence of bile-stained particles 
of mucus. Sometimes tlie diagnosis can be arrived at only by exclusion. 

If catarrh of the small intestine be diagnosed, one has to determine its cause. The 
chief things to think of are : cardiac disease or cirrhosis of the liver producing chronic 
venous stasis in the bowel ; phthisis or other forms of tuberculosis ; chronic nephritis ; 
alcoholism and the ingestion of irritants (e.g., arsenic, antimony). 

Lardaeeous Disease is a rare cause of chronic diarrhoea nowadays, and is not likely to 
occur unless there be signs of waxy disease elsewhere, e.g., in the spleen, liver, or kidneys. 
There may be a history of prolonged suppuration or tertiary syphilis. 

Tropical Diseases. — Tlie two chief tropical diseases causing chronic diarrhoea are, 
besides chronic dysentery already mentioned, sprue and hill diarrliwa. 

/ In s]3rue the jsale, frothy and copious stools are characteristic, besides the presence t)f 
a/painful stomatitis in\ol\ing the tongue and lining membrane of the mouth. It should 
ahv.ays be tliouglit of as a possibility in the case of a patient who lias lived in the East. 



DILATATION OF THP^ STOMACH 173 

Hill (Uarrhcea, which is closely allied to sprue, is met with chiefly in Europeans on 
their going to the hills after living in the tropical lowlands. The diarrhoea tends to occm- 
chiefly in the early morning, the stools being copious, pale and frothy. The diarrha-a 
is accompanied by much flatulence and distension. 

Nervous Causes. — If all the above causes of a chronic or recurring diarrhoea can be 
excluded, one may be dealing with a case of nervous diarrhoea, which is characterized by a 
tendency for the bowels to act directly after a meal (lientery) or on excitement or under 
emotional influences. A good many cases of so-called ' morning diarrhoea ' are of this 
type, though in many there is a catarrhal basis as well. The history, the presence of other 
evidences of nervous irritability, and the fact that the general health and nutrition are 
well maintained, all yield confirmatory evidence. Frequent action of the bowels may 
accompany tabes dorsalis, either in a late stage when sphincter trouble has arisen, or earlier 
in the form of rectal erises analogous to the more familar gastric crises of this disease. 

Robert ITutcliison. 

DIAZO-REACTION. — Tlic diazo-reaction of Ehrlich is obtained in certain urines 
on testing thtni with the following solutions : — 

(1) .Sodium Nitrite - - - 0-5 gram I (2) Sulphanilic Acid - - ()•."> gram 

Distilled Water - - - 100 c.c. Hydrochloric Acid - - 0-.5 e.c. 

Distilled Water - - 100 c.c. 

A strong solution of anunonia is also required, and all should be freshly prepared. 
To a drachm of sulphanilic acid solution add a drop of sodiiun nitrite solution, mix with 
a drachm of the urine, and add ammonia to excess. A normal urine turns brownish- 
yellow : when the reaction is positive the mixture turns deep red, and. most characteristic 
of all, the froth jjroduced on shaking the test tube is rosy red. 

It is often regarded merely as an obsolete test for tyjjhoid fever : but it occurs in 
many other conditions — it is an indication of abnormal protein metabolism, leading to 
the elimination of certain aromatic substances which react in this way to diazo compounds. 
The following are some of the conditions under which the diazo-reaction has proved 
pt)sitive : — Many fevers, such as diphtheria, erysipelas, measles, pneumonia, scarlet fever, 
typhoid, tyjihus ; cachectic states, such as advanced phthisis, cancer, cirrhosis, syphilis, 
malaria, gra\-c an;cmias : and as the result of jjoisoning by certain drugs, such ^ chrysarobin. 
guaiacol, carbolic acid, or opitun. 

Clearly a reaction which occurs under so many different circumstances can have but 
a limited value. There are some who say that it has no value at all ; others, however, 
find it of clinical use in the following respects : (1) It is never normal ; (2) It is more 
constantly present in cases of typhoid than in any other fever, so tliat, other things being 
e(|ual. the presence of the diazo-rcaclion may help in diagnosing typhoid fever, though 
the converse is not true ; (3) In cases of |)htliisis a positive dia/.o-rcaction is a sign of ill- 
omen, whilst should the diazo-reaction disappear alter it has been ])resent, this is evidence 
of material improvement, even though the pli\sical signs remain the same. 

Ilirbcrl I'rciirh. 

DILATATION OF THE HEART. (Sec l-Xi.MtcKMKNT ok ti.i; IIi-Aur p. 200.) 

DILATATION OF THE STOMACH presents ilself .•linically under I wo lolally 
dilierciil aspects: (1) Arule : (2) Cliriiiiie. 

Acute Dilatation of the Stomach is generally a serious complication, or often rallicr a 
fatal cataslniplic. arisins.' jti the course of some other condition, especially : 

Allcr (i|)(i:ili(iiis, iKitnlilv l:i|iiir(iliiniy. per- In llic course oT aeulc levers, csijccially 

loiiuiil I'cir uliMlevcj' cmiisi' lohar piu'unionia 

Al'lir iiliiloriiiriiil injury In tile course iif eluiinic lie;nt iMiluic. 

cspcciiilly in li.id cases ot mitral stenosis. 

'I'lu' diagnosis is uenenilly easy : it is the reli<l' of Ihc acute dilatation that is so diflicull. 
The l)lo\vn-up. druinniy abdomen, the conslani cliorl to bring up wind, somclimes In vain, 
somcliiucs willi copious and reenrretd crucial ions, often with ominous luc(ipni;li, arc 
familiar and nnieli to be dre.ided. Sometimes shortly before, sornel imcs just nllir. dciil h. 

innnense ((uantitics of blackish brown or dull greenish brown fluid flow IV Ihc moulh 

and luistrils, and the wonder is how it c;ui all be coming from one stonia<h. Tin- (lilnlnliou 
itseIC is of Ihc iialurc of aculc paralysis of Ihc gastric walls. ;in.l lh<- linn! oulllow of lluid 



174 DILATATION OF THE STOMACH 

wliich gushes out rather than is vomited — is caused by the pressure of the gas associated 

with it. an<i not by active contractions of the stomach musculature. 

Chronic Dilatation of the Stomach is due to totally different causes, which may be 
divided into two main i;rou])s. namely : — 

1. Those associated ivith stetwsis at or on either side of the pijloriis due to : — 

Cicatricial fibrosis of an old simple gastric ucler 

('i(;il ri(i;il liliicisis of ail old duodenal ulcer 

.\illi( si(.iis aiiiiind or near the pylorus, the result of former local peritonitis due to 
sucli causes as : Former gastric ulcer: Former duodenal ulcer: Gall-stones. In 
many cases adhesions are found without any ascertainable cause. 

Carcinoma of the pylorus i Rarities, such as calcified retroperito- 

Carcinoma of the duodenum ueal cyst ; hydatid cyst at tlie portal 

Carcinoma of the nall-bladdcr ! fissure ; huge renal tunioiu-. 
Carcinoma of the head of the parcrcas 

2. Dilatation without obstruction : — 

Atony. Ovcr-distentioii by gas or excess of food or drink. 

In the consulting room tlic two most suggestive signs of dilatation of the stomach are : 

(1) A gastric succussion splasli, audible or palpable over a much wider area than normal. 
Tlie mere presence of succussion is not an indication of dilatation, for a normal stomach 
containing fluid and gas gives marked succussion. The point to determine is the area over 
which the succussion is heard : and if it extends right across the epigastrium and down to 
the umbilicus, or below it, when the patient is lying down, dilatation is almost certain. 

(2) Visible gastric peristalsis over an unduly large area (p. 521). The most important 
symptom when there is pyloric stenosis is the vomiting at relatively long intervals of larger 
ipiantities of material than were consumed at the last meal, especially if remains of a meal 
taken the day before can be recognized in the vomit. A very important jioint to remember, 
however, is that even a marked degree of pyloric stenosis, with extensive dilatation, may 
he iiresent in a patient who never vomits at all. This has been proved again and again 
1)\- bisnuith and .r-ray examinations followed by ojieration. It is by the a'-rays that the 
diagnosis is made best, especially by a series of examinations after the original bismuth 
meal. If the bismuth is taken at 11 a.m., none should be seen in the stomach at 6 p.m. 
Very often in these cases, however, the black shadow is still obvious in the stomach, even 
at 11 a.m. on the following day — after twenty-four liours, and in some instances for longer 
still. It is generally easy to see the active peristaltic waves of the stomach at the same 
time, and thus distinguisli between the dilatations due to obstruction, and atonic dilatation 
in which the stomach wall has sagged down and remains motionless when seen with the 
.I'-rays after bismuth. Skiagraphy is infinitely superior to any other method of diagnosis 
in these cases, and is replacing diaphany, lavage, inflation, and gastric juice analyses where- 
cver available. At the same time it is often possible to detect such diHiculties as hour- 
glass stomach, or to distinguish ulcer from carcinoma. Once dilatation from stenosis has 
been demonstrated in this way, operative measures are indicated, for medicinal treatment 
cannot cure the mechanical stasis. The further details of the diagnosis are arrived at by the 
surgeon ; even when the abdomen has been opened, however, it is often exceedingly 
dillicult to decide whether a given hard mass at the pylorus is malignant, or due to inflam- 
matory matting round an old simple idcer, and it may remain in much doubt which of 
the two is present until one finds that the patient survi\es for years after his gastro- 
enterostomy, and thus demonstrates that wliat was tliought at the time to be a carcinoma 
must after all have been not malignant, but the result of inflammatory matting round a 
simple ciironic ulcer. Herbert Frciicli. 

DIPLOPIA, or double vision, may be citlier monocular or binocular : that is to say. 
an object may be seen double with one eye, or single with each eye separately, and only 
double when both eyes are open. To distinguish between the two conditions it is necessary 
that each eye should be closed in turn. If with either eye the object is still seen double, 
the diplopia is monocular and due to that eye alone ; if, on the other hand, the object 
is seen double only when both eyes are open, the diplopia is binocular, and due to some 
disturbance of the balance of the two eves. 



DIPLOPIA 175 

Monocular Diplopia may be due to : (1) Dislocation of the lens ; (2) Incipient 
cataract ; (3) Double pupillary apertures : (4) I^ow degrees of astigmatism. 

In a case of monocular diplopia it is necessary to examine the eye by light reflected 
upon tlie pupil from an ophthalmoscope mirror in a dark room. Diplopia from a dislocated 
or (Usplnccd lens will only occur when the edge of the lens is in the pupil, some rays passing 
outsi<ie tlie lens direct to the macula, and other rays, passing through the edge of the lens, 
being dellected to a different part of the retina. In these circumstances the edge of 
the lens will be seen in the pupil as a dark crescentic opacity of unmistakable form and 
api)earance. Other sym])toms which may serve to confirm the diagnosis are increased or 
irregular depth of the anterior chamber (the space between the iris and the cornea), and 
tremor of the iris during movements of the eye. 

Early cataract usually leads rather to the appearance of multiple images, than of 
two only, a candle or light being seen as live or six. This polyopia is due to the fact that 
till' lens is broken up by cortical cracks and opacities into sectors of varying refractive 
power, very often set in slightly different planes. These cracks and sectors of the lens 
will be seen easily as black radial opacities on illumination by an ophthalmoscope mirror, 
or as opaque white striic when the eye is ilhmiinatcd from the front by a lens. 

The ])resencc of /a'o piipillarii apertarcs will be at once ai)|)arcnt f)n a careful examina- 
tion of the eye. They may be congenital, or due lo accident or o])eration. In cases of 
diploijia due to multiple pupillary apertures, tlu' double vision is most evident when the 
ol)jecl looked at is not in accurate focus. 

.Should none of the three conditions mentioned above be foimd, it is most likely that 
the diplopia is due to a fote error of refraelioti. In this condition letters and test tyi)es 
arc often seen accompanied by faint " ghosts " ])laccd either above or to the side of the 
real letters, and in some cases over-lapping them. This cause of monocular diplopia can 
only be determined by a careful examination of the refraction of the eye. The diplopia 
is iMiicd by tlic wearing of silitable glasses. 

Binocular Diplopia may be either (1) Physiological or, (2) Pathological. 

J'lii/sioloiiicdt (lipyi/iia occurs imnoticed in all normal binocular vision. It is evident 
that as thf' two ejj^view any given object from diflcrent standi)oints. the retinal images 
must differ as •♦♦♦r the two views taken by a stereoscopic camera. The diplopia is not 
apparent, however, as the two dissimilar images are combined by the higher visual centres 
of the brain to form a single solid conception of the object viewed. The amount of 
dis-similarity of the retinal images gives the impression of sjiace and distance, near 
objects causing images more unlike than those formed by things remotely ])laeed. The 
dis-similarity of the two retinal images in normal binocular vision, giving (he idea of 
s|)aee, is termed in psychology ' disparateness ' or ' dis])aration." 

When, however, owing to some failure in the centre which eonlrols llie iuciiImI fusion 
of the two ocular images, they arc not combined, or when some disturbance ol llic :iceurately 
balanced nmseular mechanism upsets the automatic fixation of both cv( s upnri Ihc same 
object, pathological, or ob\ious diplopia results. 

I'litholdiiical Dijiliijjia- IJel'on- discussing the various forms and causes of this con- 
dition il is, necessary to have a elcMr idea of the visual process of localizing objects in space 
priijeelinn. cir orientation. 

Ill normal liiiioeiilar vision, looking at an object means liial both eyes are so turned 
that the image of the object looked at falls upon tlie central most acute area of the 
retina, tin- macula or yellow spot, in each eye. and objects other than that directly 
looked at lorni images upon the retina which are more or less peripheral. From our 
experience of such sensations and their localil\ on the retina we .arc able accurately 
to (lelenniiie Ihc relative i)ositions of objects in space. The image of any object will 
always fall upon corresponding areas of Hie rcliii;e of Hie two eyes. These areas, though 
always corresponding, are not in Hie line sense ol Hie vvoid syiniiictrical. The image 
of an object to the right of the eyes tails upon Hie nasal side of the righl and the 
temporal side of the left retina : but the corresponding areas arc in normal cireuin- 
stanecs always stimulated siiiinltaneonsly, and bcmi these retinal images is derived the 
idea of the posilion of Hie olijcci in space. 

n llic normal iclalivc posilion ol Hie two ey 
olijeel no longer \;,\\^ upon luo iisu.ill\ idrres| 



np^ 


.el 


ill 


an\ 


way 


Hie 


Ini 


age ( 


.1 an 


lie; 


IS. 


crri 


mil' 


oils ill 


Ic.-is 


ofl 


iroje 


etioii 



176 DIPLOPIA 

are formed, with consequent diplopia, and it is from an examination of tliis diplopia that 
we can ascertain the displacement of the eye and its probable cause. 

For example, Fig. 81 represents diagrammatically a condition in which the left eye 
is looking at or fixing the object O, while the right eye is pointing abnormally inwards — 
a convergent strabismus. In consequence of the abnormal position of the right eye, the 
image of the object O does not fall upon the yellow spot on the macula, /, but upon a point 
internal to it, a. In ordinary circumstances, with proper fixation of the two eyes, any 
object whose image fell upon a would be to the right of the object O, hence under the exist- 
ing abnormal conditions the right eye erroneously projects the object O to the position O', 
and a diplopia results in which the right of the two images seen belongs to the right eye. 
and the left to the left eye. This is termed a homonymous diplopia. Fig. 82 shows in a 
similar manner the formation of a crossed diplopia in a divergent squint or strabismus. 
These two figures illustrate the formation of a diplopia in lateral deviations of the eyes. A 





Fi'j. SI. — Homonymous double 



Fifj. 82. — Crossed double im;xges. 



moment's consideration will show that deviation in a vertical or oblique plane will equally 
cause diplopia, owing to the disturbance of the normal corresponding areas of the two 
retinae. 

It will be seen from the figures that, in lateral deviations, a convergent squint causes 
homonymous, and a divergent squint crossed, diplopia. In ocular paralyses the diplopia 
will increase if the two eyes are carried in the direction of the usual action of the paralyzed 
muscle. As an example. Fig. 81 may be chosen as a diagrammatic representation of a 
paralysis of the right external rectus muscle. The more the eyes are turned to the right 
the greater will be the convergence, owing to the inability of the right eye to turn to the 
right to the same extent as the left ; the greater therefore will be the diplopia as the image 
of the object O falls farther and farther round on the nasal side of the right retina, the 
object being projected farther and farther to the right. It will also be seen from this con- 
sideration that in a case of diplopia from a muscular paralysis when the eyes are carried 
as far as possible in the direction of the usual action of the paralyzed muscle, the farthest 
displaced image always belongs to the paralyzed eye. 

The two images are not equally distinct. That in the unaffected eye falls upon the 
macula and is seen most distinctly ; this is called the real image. That falling upon the 
retina of the affected eye is more peripheral, and tlierefore not so definite : it is termed 
the false or apparent image. 

With the above considerations in view, and with a knowledge of the individual actioiis 
of the ocular muscles, it is easy to elucidate cases of simple paralysis of one or more ocular 
nuiscles, but for convenience of reference the chart giving the position of the images in 
paralysis of the various ocular muscles is reproduced on the following page. 

Binocular diplopia may be caused, as suggested above, by paralysis of ocular 
muscles, but it may also arise from the bodily displacement of one eye from 



DIPLOPIA 177 

orhilal groiLth. ahsrcs.s. t>v iKvmorrliagf. It may also occur after some operations for 
tenotomii. 

Cases of displacement of the eye from local causes can usually be distinguished from 
those of ocular paralysis by the indeterminate character of the diplopia, which is accom- 
j)anied by more or less fixation of the eyeball, and by proptosis. 

Fig. 83. — To Il.H"STR.\TE THE BEH.iVIOUR OF THE DoUBLE I.M.^GES 

IN Paralysis of the Ocular Muscles. 

T.eft-sideJ Risht-sided 

I'aralysK. Paralysis. 

The dotlfid lines Tcjinsent the apparent image. 

J I External Rectus. I ! 

• I Diplopia appears in looking toward the paralyzed side. I ■ 
I I The lateral separation of the images increases as the paralyzed eve I ■ 

• I is abduftcd. ■ ■ I ■ 

II liiteniiil Hccltis. • | 

■ Diplopia' on looking towards the sound side. J | 

i The later separation of the images increases in adduction of the iiaia- ■ I 

J ly/cd eye. • 

Sujicritir /{edits. ^ 

f Diplopia on looking up. o 

• The vertical distap.ec between the images increases as the paralyzed % 

» eye is elevated and abducted. o | 

I The obliquity increases in adduction. D 

Tiie lateral separation of the images diminishes when the eyes are | 

turned laterally iu either direction. | 

Ilttfetwr Uerltts. . 

Diplopia on looking down. I 

The vertical distance between the images increases as the ]iaraly/,(il I 

eye is depressed and abducted. , I 

• The obliquity increases in adduction. f 

• The lateral separation of the images diminishes when the eyes .ue » 
« lurued laterally in either clireetion. • 

Sit/iniDr Olitiiiiir. I 

I Dipl<>]>ia on looking douri. I 

I 'I'lie vertical distance between the iniaL'es increases as the paralwcd I \ 

/ I eve is depressed and a.ldueted. | \ 

f ' Til.' ulili.|Mily iuereasi-s with the abduction. \ 

,* Tlic iateial distance between the images diminishes when tin- eyes ♦ 

* arc turned laterally iu either direction. 

litfiriiir Ohiiijiii-. 

♦ Diplopia on looking ii|i. f 
\ The vertical distance lietw.cri the images im-reases as llie paialv/.rd ♦ 

\ I eve is elevated and addu<-ted. I / 

• I The oblicpdtv im-reases with Die abduction. I ♦ 
I Tlie lateral distance bitwceu tlie images increases as tlu- e\c is I 

I elevated and abducted. I 

Isolated paralyses oi iiidix idiial ocular- rnus(-l(-s or gr-iiiips of muscles an- iK-arly always 
niK-leai- in origin : basal gi'owllis rar-i-ly (-aiisc ocular par-al\s(-s of any cNl(-nt on out- side 
iiidy. the aliection sooner or later becoming bilali-ial. 

In some rare cases of con\-cT-g(-id or ili\(-rgcid sipiini with absiri(-i- of brno(-ular \isioii 
and good vision in ca(-h eve. Ilii-rc- may bi- tlu- power of alternate fixation with nioic or less 
evident diplopia. As a rule. h(nv(-\er- tlie iirdividual has the power of suppressing the 
image- of the si|uiiilirig (-yi-. nbtainirig riiorio(-ular vision. Ilcrhcil I.. AVvok. 

DISCHARGE FROM THE EAR. (.S.-(- OioaumKA. p. i-ii.) 



DISCHARGE, NASAL- 



DISCHARGE, NASAL. — A discharge from the nose may be acute, subacute, or chronic 
and it may consist of clear fluid almost like water, of mucus, muco-pus. pus, food regurgi- 
tated through the nose, or blood. For the differential diagnosis of the causes of haemor- 
rhage from the nose, see Epistaxis. p. 220. 

Regurgitation of Food through the Nose may be due to a congenital condition, 
especially cli-fl-pfilatc : to accpiired pcrfoidtidii of the palate, especially syphilitic : to posl- 
(Uphlhcritir panilfisis : or to nuich rarer n< uro-muscular lesions, such as bulbar paralysis, 
psei((l(ibiilbiir paralysis, or iiiyaslhciiia graiis. all of which are discussed elsewhere. 

Serous, Mucous, and Muco-Purulent Discharges differ from each other chiefly 
in degree, for that which may begin as serous may later become muco-purulent and then 
purulent, as is seen during the course of a common cold. A watery discharge is sometimes 
spoken of as coryza, though for the latter to be typical there should at the same time be 
watering of the eyes ; it is generally acute in onset, and the diagnosis of its cause is not 
difficult as a rule. It may be due to the following different conditions : — 



Comnioncold, early stage 

(Micrococcus catarrhulis) 
Lachrymation 
Hay fever (coryza e feiio) 
Measles 
Indism or bromism 



Arsenic 

Local irritants sueli as snuff, 
ammonia vapour, sulphur 
dioxide, chlorine, and other 
irritating gases 

Fog 



Some cases of spasmodic 

astlima 
Some cases of trigeminal 

neuralgia 
Neurosis 



The differential diagnosis of these conditions needs little discussion, a careful inquiry 
into the circumstances of the ease generally pointing to its nature at once. Measles 
probably ])resents the greatest difficulty, for the coryza precedes the macular erujition, 
and the iiatient. generally a child, may seem to be suffering merely from a severe cold, 
when in reality it is in the most infectious stage of measles. Examination of the buccal 
mucous membrane for Koplik's spots (Plate VIII) may sometimes serve to distinguish this 
malady as long as two days before tlie eruption appears. These spots are individually 
small, with a whitish centre the size of a pin's liead, surrounded by a purplish red blush ; 
in many cases they are not single, but collected into groups of from two or three to thirty 
or more ; a common place to find them is on the inner aspect of the cheeks in much the 
same position as that in which one expects to find brown pigmentation in Addison's 
disease ; but they should be looked for also on the gums, the inner aspects of the lips, 
and on the hard and soft palate. 

The coryza resulting from iodide or bromide of potassium or from arsenic may be very 
severe, and the patient generally complains of constantly catching cold, when in reality 
the symptoms are due to the drug. 

'I'he term iiijlaoiza is sometimes applied to severe febrile colds associated with 
running of the ejes and dripping at the nose, but it is often inaccurate to apply the term 
influenza here, for the symptoms are more often due to the Microeoccns catarrhalis. 
Haeteriological detection of the Bacillus influenzce in the discharge is essential if influenza 
is to l)e diagnosed with accuracy. 

Excessive secretion by the lachrymal glands apart from emotion may. in some 
instances, lead to constant dripping of water from the nose as the result of neurosis. 

One rare form of watery discharge from the nose is the escape of cerebrospinal fluid : 
this fluid is perfectly transparent, like water, and it may be difficult to recognize its true 
nature unless there is a clear history of the commonest cause for the symptom, namely, 
an injury to the head leading to fracture through the base of the skull, involving one of 
the anterior fossae. The fluid may dri]) steadily, at the rate of a certain number of drops 
l)er niiiuite. and if it is collected in a test-tube it may be found to reduce Fchling's solution. 

.\ purulent discharge from the nose may result from that which has been in the first 
place serous, mucoid, or muco-purulent ; or it may have been purulent from the beginning. 
If it is acute and bilateral, it is probably due to a local infection by some pyogenic micro- 
organism, and even when it may seem to be due to nothing more than a common cold, 
not a few different organisms may be disco\ered baeteriologically. Sta|jhylococci, strejjto- 
cocci, and pneumococci (see Plate XX]'III. p. 61-f) are associated not at all infrequently 
with the Micrococcus catarrludis. Influenza bacilli may be found. In rare cases, especially 
when the purulent discharge persists longer than it ought if it were the result merely of a 
cold, and especially in eases in which it is so acrid as to produce superficial excoriation and 



PLATE VIII. 



KOPLIKS SPOTS 



^^ 






INDEX OK DI.KINOSIS -Tn Ian 11. 178 



DISCHARGE. NASAL 17'.) 

soreness of the ctlges of the nostrils and the iiijper lip. diphtheria haeilh will be found more 
often than might be expected. Xnsal diphtheria, indeed, is not altogether iineoninion, 
but it is difficult to recognize except by bacteriological examination of the nasal discharge. 
The same applies to two very mudi rarer purulent lesions of the nose, namely those due 
to gnitococci and to ^hinders. There may be a urethral infection or a vaginal clischarge to 
point to the diagnosis in the former case, the patient having transferred gonoeocci direclly 
from the genital source to the nose by means of the fingers or a towel. Purulent rliiTiitis 
due to glanders is fortunately rare, though when it does occur it may escape recognition 
entirely in its curable stage, unless the patient's occupation as a groom or horse-dealer 
suggests the source of the infection, or unless bacteriological methods are resorted to in 
all cases of nasal discharge that are not perfectly straiglit forward. 

Chronic purulent nasal discharges are for the most part due either to lesions of the 
iiiucous membrane or to the emptying into the nose of purulent collections from tin 
antrum of Highmore. frontal, ethmoidal, or sphenoidal sinus, or from necrosis of the nasal 
bones. The tliagnosis may be ob\ious enough, but very often it is by no means easy. It 
is essential that both nasal cavities should be insi)ected directly in a good light by means 
of a speculum and mirror : the various kinds of chronic rhinitis may be recognized in this 
way : in chronic alni/iliiv rliiiiilis the amount of discharge is usually small, the cavities of the 
nose are relatively spacious, the smell offensive (oza-na), and there are generally crust-like 
deposits upon the mucous membrane. Chronic hypertrophic rhinitis may also produce 
a very offensive smell, a considerable purulent discharge, and difficulty or even inability 
to breathe through the nose owing to the bulging of the inflamed mucous membrane. 
There may or may not be poli/pi at the same time, and perha])s adenoids and enlarged 
tonsils owing to the necessity for breathing through the mouth. Mend/ranoiis rhinitis is 
not a distin<'tive variety, it being more or less an accident whether the inflamed mucous 
membrane produces a membranous exudate or not ; the discovery of membrane would 
suggest diphtheria, hut bacteriological examination alone can determine whether the 
lesion is diphtheritic or not. Si/philis is responsible for a large number of the ca.ses of 
oziena and chronic rhinitis, especially of the atrophic form, but it is not responsible for 
all. and the iliagnosis as to whether the lesion is syphilitie or not will rest upon eoiieoniitant 
signs elsewhere, upon the history, and upon the result of Wassermamrs reaction. Necrosis 
of the nasal bones, if it occurs spontaneously, is often syphilitie, but it may also result 
from an injury, such as a blow ; the deformity which follows the falling in of the bridge 
of llic nose is cliaracteristie. 

'ridx-nii/iiiis rhinitis is rare. There is a \ariety of nose affection callcil rliiiiilis iiiscosa, 
but this is acute and not tuberculous: the appearances might at llrsi suggest thai the 
nose was lilled with a yellowish diphtlieritic membrane, but on culti\iition no diphtheria 
bacilli are to be foimd : what micro-organism is the cause of the cheesy exudate in these 
ca.scs is not known ; if left, the unclrrlyJMg mucosa is apt to iileerate. but under simple 
antiseptic treatment cure rcsulls in a week or a little more, liliiiiiililhs. although they 
may cause persistence of a nasal discharge, are not in themselves a primary condition, 
liiil rather tlie result of preceding rhinitis. Kndotlielionia. eareinoniii. or siircoinii alleeting 
llic nose ftre not common except as the result of direct s])read to its interior from the lip, 
jaw, clicik. (ir forehead. .Sometimes, however, considerable nasal discharge may result 
Irnm the ginwlh of a semi-malignant tumour known as recurrent JUiroma lyr Jilno-sareoma 
arising fiDiii llic external periosteum of the basi-sphenoid bone, thus ohsl ruci iiig the hack 
of the noM . and detected by a digital examination \ia the moutli. 

A forciuii hodij inserted into the nose by a child or by an insane person max produce 
damage assdciatcd with a purulent discliarge, wliicli ma\ prrsisi e\(ti allir llie rorcign 
body has liccn detected and n inovcil. 

I.ii/His of llic nose is hardly (Mr primarw ami although it may destroy the margins 
and lead lo :i purulent disiharge Ikjiii tin- nusl ills, the diagnosis is generally clear from 
I 111 appl(-|ell\ deposits in the adjacent skin of the cheeks. Ilodcnt nicer, on the other 
iiaiid, lliougli starting in the skin, may spn^ad deeply into the nose, causing destruction ot 
caililage and hone, with ))ain and purulent discharge. Whereas lupus starts in early a<lull 
lilc. lodeni ulcer begins at or alter middle age. Histological examination may li<' rei|uii(il 
111 dislinuuisli it from e/iithclionia. thouiili the latter is likely lo fimgate in<irc and In ha\<- 
advanced mun- rapidl\ than nidciil ulcer does: the lallcr may ha\c esislcd fur years 



ISO 



DISCHARGE. NASAL 



without any rapid advance. Radium treatment, ediciently applied, will cirre most rodent 
ulcers of the skin, but this therapeutic test is no longer api)licable when the cartilages and 
l>ones of the nose have become involved, for raditmi is then not able to cure the rodent 
ulcer any better than it can cure lupus or epithelioma. 

Kmpijetna of one anlnim of IIis.hmore may cause most troublesome jjurulent discharge 
from the nose, but it is not dillicult to diagnose when the symptoms arc definite. The 
patient generally complains that the ])us invariably comes down one nostril ; that it is 
associated with an odour which is offensive to himself in a way not common with ozaena 
generally ; that he can often produce the discharge by tilting his head sideways in the 
opposite direction to that from which the discharge comes, and that he experiences dull 
aching jsain in one side of the face, often sjioken of as neuralgia, but upon investigation 
proving to be associated with tenderness located mainly in the corresponding superior 
maxilla. There may be a carious tooth, particularly a canine, from which infection of 




Fig. 81.— Transillu 



ions of the aiitnuii. yi shows the normal appearance. B sliow^ no inuminjition of the 
dit side, owiiis; to purulent contejits. f From ilaliail Amiiial. loOB.I 



the anlrum has taken [ilace. though in a small number of cases a nH)re serious cause exists, 
namely, carcinoma or endothelioma of the antrum, which can seldom be diagnosed until 
either an operation is undertaken or the growth itself begins to cause a ])rotuberance either 
info the nose or through the face ; the nature of these growths is determined histologically 

Examining the patient in a dark room by the introduction of an electric lamp into 
the mouth or posterior nares. may reveal empyema of the antrum by the trdnsilluniination 
of the superior maxilla of the normal side and the opacity of the other in which the antrum 
is full of pus (Fig. S4). 

Empyema of a frontal sums has generally been preceded by acute nasal catarrh, which 
has led .subsctiucntly to severe aching above one or other eye, with tenderness on jjercussion 
over the affected frontal sinus, and so much pain in this region that the patient may be 
compelled to hold his head before he is able to cough or blow his nose, because of the 
increased pressure within this sinus due to either of these acts. The condition nearly 
alwa\s starts acutely, though if untreated it may become chronic and come under 



DISCHARGE. URETHRAL 181 

observation only when the , infection has tracked its way through into the subcutaneous 
tissue so as to point above the eye or in the angle between the latter and the nose. 

Siippiirdtiun in connection ivilh the etlimoidal or splienniilti! sinuses can be little more 
than guessed at unless special skill has been ae(iiiired in the direct examination of these 
air-eells. If, however, there is a purulent discharge from the nose coming apparently 
from high up, in a patient who has neither antral disease nor infection of the frontal sinus, 
and in' whom local conditions of the mucous membrane of the nose itself can be excluded, 
infection of the sphenoidal or of the ethmoidal cells is to be suspected. Herbert French. 

DISCHARGE FROM THE NIPPLE.— Discharges from the nijiple may he divided 
into three classes :-(!) Xon/ial discharges; (2) Xiirniti! discharges at (ilmornud lime':; 
(3) AhiKinnal iliseliiirges. 

Normal Discharges. — It is quite natural for a woman during the period of 
pregnancy and lactation to have a discharge of milk from the breast. It is usually of 
small amount. exee|)t when the child is ])ut to the breast, but occasionally the flow at other 
times may lie sullieient to be distressing. 

Normal Discharges at Abnormal Times. — .^lilk may come from the breast at other 
times than dming pregnancy and lactation. In infants it may be found as the result of 
undue stinuilation on the part of the nurse, and it has been noted in the breasts of both 
sexes at the time of puberty. Xo great imjMjrtance attaches to it. 

Abnormal Discharges. — Blood or Blood-stained Discharge. This is a very significant 
sign and should not be neglected, for it almost always indicates the presence of some 
abnormal condition in the breast which re<|uires careful in\ esfigation. The commonest 
is some growth involving the larger duets in tlie neighbourliodfl of the nipple. This may 
be cither innocent — a duct papilloma ; or malignant — duet carcinoma, scirrhous carcinoma. 
Ill- sarcoma. It behoves one therefore never to neglect such a significant sign. When a 
well-marked lump is felt the diagnosis can usually be made without difficulty, and for this 
the reacler is referred to the article on Swellim;, M.v.M.M.Mtv (|). (IS.")). DiHiculty arises when 
there is no obvious swelling. In these cases the breast nuist be palpated carefully with 
the Hat of the hand and also with the tips of the fingers, special attention being given to 
the part imtncdiately subjacent to the nipple. If no swelling can be made out, and the 
bleeding remains a persistent sign, it may become necessary to make an incision into the 
breast for diagnostic purposes, recognizing the fact that a papilloma may be so delicate 
as to escape detection with tlie finger. I'robably the commonest cause of lileeding is a 
duet carcinoma ((Milumnar-cellcfl carein(inia) : al'ler Dial (Incl papillmna ami seirrlious 
can'inoma. and last of all sarcrnna. 

.\ /Hirideiil discharge, nr pus mixed with milk, generally indicates acute suppiu'ative 
mastitis ; the dtlicr signs of inflanunation or abscess are well marked as a rule, so that there 
is no difficulty at arriving at a diagnosis. Chronic' mastitis seldom causes a discharge 
of pus from the nipple, but the symptom is met with sometimes when the lesion is tuliereu- 
hius : the discovery of tubercle bacilli in the discharge will distinguish this from carciiioina, 
with which it is often confused. 

A dimharge of serum will suggest chionic iiitcisl itial mastitis with e\ s| loi-mation. 
lint the symptom is rare. 

fli/datid fluid has l)een recorded as escaping through tlie nipple from a lii/didid ei/st 
of the bn-Mst. bill it is so rare as to be a pathological curiosity. 'I'lii- naliiir of the Ihiid 
would lie iceogiii/cd liy the finding of hooUlels in it {P'ig. 18. p. HI). ^V^/i'. /■; r.-i.v/,- 

DISCHARGE, URETHRAL. Any iiillainiiialorx process in tin- urethra causes a 

diseliaigc. Allhongh most eoi iily the icsiill of inf'ectjoii by tin- gonocoecus, by no 

means e\<rv urethritis is of this nalure. and bacteriological examinations show thai other 
organisms besides the gonoeoc'cus may produce a urethral discliaige and the same syrn- 
jitoms as an acute gonorrhiea. Further than this, a piiriilent discharge may occur in 
wliieli no micro-organisms can be found: for instance, when the urethra has been injured or 
subjected to irritation by the injection of strong solutions, or when it contjiins a foreign body, 
such as a ealculns or a retained eallietir. It is s|al<(l that a urethral discharge may be 
associated with gnul and rheuuidlisiii : liiil alllioiit;li a leu easi's of the former have come 
under my care. I lia\c been unable lo pro\ e llial llie small amount of discharge was not 



182 DISCHARGE. UKETIIHAL 

tlic remains of a former uncured uretliral infection, or that it was directly due to the same 
source as the arthritic symptoms. 

There is no doubt that an acute urethritis may be caused by otlier organisms than 
tlic gonococcus, and sometimes there is considerable trouble in conijjletely curing it. 
These cases may cause complications in the genito-urinary organs similar to those due 
to the gonococcus, such as prostatitis, epididymitis, or cystitis. They may arise by the 
infection of the urethra by septic instrumentation, or after connection with a woman 
subject to leucorrhoea. A careful bacteriological examination should always be made ; 
more than once the reputation of a wife has been at stake until it was proved that the 
husband's urethritis was of staphylococcal and not gonorrhoeal origin. An acute urethritis 
may accompany a ha?matogenous urinary infection : for instance, an acute pyelitis due 
to bacillus coli may be followed by acute cystitis, prostatitis, and urethritis, in which no 
other (irganism liut llai-iHiis coli can be found. 

Gonorrhoeal Urethritis is due to the infection of the urethra by the gonococcus of 
Neisser (Plate XXVIII, Fig. R, p. 614). In form it is a diplococcus with flattened surfaces 
approximating each other : it stains readily with basic aniline dyes, but differs from other 
diplococci in being decolorized by Gram's stain. The gonococcus is seen in a stained 
s|>eeimen to be iiilidcclliiliir. penetrating not only the leucocytes but also the epithelial 
cells found in a smear ]jreparation, and, though the cocci may be found also between the 
cells, their appearance in the cells is strong evidence of their specific nature. 

In any case presenting a purulent discharge from the urethra, it is necessary, in order 
that a])propriate treatment may be carried out, to ascertain the extent of the infection, 
not only in the urethra itself, but also in the other organs of the genito-urinary apparatus. 
For the ]>urposes of clinical investigation, the urethra is divided into anterior and posterior 
portions, separated by the membranous urethra, the anterior comprising the bulbous and 
penile urethra, and the jiosterior the ]jrostatie portion. A urethritis is also, according to 
its clinical aspect, acute or chronic, the acute form being characterized by a thick, creamy. 
])urulent discharge, with pain, and the chronic by a thin, greyish, niuco]iurulent discharge. 
Acute gonorrhoea affects not only the superficial layers of the urethral mucous membrane, 
but also the subejiithelial tissues and the glandular elements, causing a leucocytie infil- 
tration. The tendency of the inflanunation is to spread Iwckwards along the canal, so 
that the prostatic urethra may become infected, even in the acute stage, tfiougli most 
frt'quently this occurs at a later period : the prostatic and the ejaculatory duets may 
become infected, and the inflammation may spread to the seminal vesicles, epididymes. 
or testes. In the acute stages of the disease, the infection of the anterior urethra is accom- 
panied, as a rule, by redness of the external meatus, scalding pain during micturition, 
and painful erections ; occasionally all pain is absent, especially in patients ])reviously 
infected with gonorrhoea. If the anterior urethra be irrigated with .sterile water or saline 
solution, the urine passed immediately afterwards will be quite clear ; or without irrigating, 
if the urine be passed into two glasses, the Hrst portion will be turbid from admixture with 
the urethral discharge, whilst the second |)ortion remains clear. 

When the jjosterior urethra becomes infec'ted in the acute stages, the symptoms are 
nuieh more severe. Micturition is more painful and greatly increased in freciuency, Ijoth 
day and night, the patient often being obliged to ])ass urine every half-hour. Even after 
irrigating the anterior urethra the urine jjassed will be turbid with pus that has acciunu- 
lated in the jirostatic portion or passed backwards into the l^ladder. and tlie terminal lu'ine 
may be tinged with blood. In these circumstances it may be necessary to eliminate nnitc 
prostatitis or prostatic abscess, either of wliich may complicate an acute posterior urethritis. 
In either condition, micturition may be very painful, or there may be acute retention : 
the temjierature will be raised, and in cases of abscess there is often a rigor ; upon rectal 
examination, the prostate is foimd much swollen, hot to the touch, and extremely tender, 
wfiilst with an abscess a soft fluctuating area may be felt. An acute posterior gonorrhoea 
is practically always accompanied by infection of the bladder, and the diagnosis between 
it and cystitis is practically impossible. 

Under suitable treatment an acute urethritis may remain confined to the anterior 
urethra and clear up, Ijut in less favourable cases a slight discharge remains. If this 
continues for longer than six weeks after the initial onset, it is spoken of as chronic gonor- 
rhwa or gleet. The discliarge is small in amount, thin and watery, or may be so sliglit as 



DISCHARGE, URETHRAL 183 

only to be present in the morning after a long period of freedom from urination, or as 
filaments in the urine. There is no pain or increased frequency of micturition, and there 
is no difference in the subjective symptoms between an anterior and a posterior infection, 
altliougli in most cases of chronic gonorrhoea both are present. 

In any case of chronic urethral discharge, examination should be conducted to 
ascertain not only the seat of infection, but also the nature of the lesion promoting the 
discharge. Thus, the patient should be directed to hold urine for at least three iiours 
before he presents himself for examination, when the anterior urethra may be irrigated 
thoroughly by a fairly forcible stream of sterile water, the urinary meatus being alter- 
nately occluded and opened during the ])roeess, so that the whole lengtli of the anterior 
urethra is disten<Icd by the fluid. The washing is then examined for any threads, which, 
if present, must proceed from the anterior urethra. The patient is then directed to jjass 
urine into two separate glasses ; if there is turbidity due to excess of phosphates, this is 
cleared by the addition of acetic acid, when, if any threads or plugs of mueo-]}us are present 
in the first specimen, they probably arise from the posterior urethra, whereas pus and 
turbidity of the second show that cystitis is present in addition. If there be any threads 
in the posterior urethra, or if only a small amount of discharge is present, it is advisable 
first to fill up the bladder with sterile fluid by direct Janet irrigation, after which the 
prostate is massaged by a finger in the rectum, and the patient is again directed to pass 
I lie fluid from the bladder. Plugs of muco-pus will be found if chronic prostatitis is 
present. In any case the threads from either the anterior or posterior urethra should 
be spread as a film, stained, and examined under a microscope for jnis and micro- 
organisms. 

If the remaining infection is found to be limited to tlie anterior urethra, the latter 
should be examined under direct vision by the endoscope. A few minims of a 3 per cent 
solution of cocaine are injected into the urethra and, with aseptic precautions, the largest 
sized endoscope tul)e that the meatus will admit eond'ortably is passed for about an inch. 
The canal is then illiutiinated. and at the same time distended witli air by means of the 
inflating bellows attached to the instrument : each part of the anterior urethra can then 
be examined successively as the endoscope tube is jiassed gradually on until the membranous 
])ortion of the canal is reached. It will be found much better to examine the urethra in 
this manner than by first jjassing the instrument to the full extent and examining the 
<'aiial as it is withdrawn, for any infection of the urethral glands, infiltration of the walls, 
or granular areas are observed under aero-distent ion before the instrument has ])asse<l 
oxer Ihcni. When the whole length has been cxanilncd imder distention, the air is allowed 
to cscMpi- by opening tlie wItkIow of the instrument, and the canal again examined I'roni 
licliiriil lorward by gradually withdrawing the tube, normal urethral walls falling togetlier 
ill a cliaiaeteristie striated manner, which is altered into a slight rigidity by infiltration, 
whilst al the same time glandular infeetion or uleeratioii is again seen. .Similarly, a ilelinite 
stricture or a small polypus which may keep up a slight uiclliral disrliaigc can be dia- 
gnosed with certainty, an<l any local treatment for the various lesions applied. Hy earerul 
examination conducted on these lines we are able to determine, not only which part of 
the urethra is iirodiieing the discharge, but also the nature of the lesion, so that appropriate 
treatment can be carried out. In most eases in which a gleet remains in spite of treatment 
with various kinrls of injections, it will be found that there is an infeetion of the posterior 
iiicllira or prostatic duets, which no urethral injection except a comiilcte irrigation into 
Itic liladder will reach. There is often no abiiormalily to be <leteeted (Ui digital 
iNaiiiinalioii of the prostate ])er rectum; but after urethial irrigation the secretion 
s(|ii((/,cil mil from the ])rostatc by massage will usually show pus corpuscles in addition 
ti) till- ictiaelile globules and epithelium which are contained in the normal jiroslatie 
secretion. In other cases of obstinate chronic urethritis, a distinct inlilt lal ive proee>^ 
will be found in the anterior urethra, a process which results in rigidity of the iirelliral 
wall, and in severe eases leads on to stricture. The uielliral glands are implicated, and 
llicir secretion gives rise to the filaments in the urine. This inliltration is seen readily 
l>\ urethroscopy, but it may be imperceptible on I lie piissage of a sound. The urethr.al 
meatus is the narrowest part of the canal, and a sound uliidi will eoniplcdly lill I he meal us 
may still pass steadily through an inliltnited portion of Ilii- iircllira. e\eii when its normal 
calibre is diniinish<d eonsiihrablv. 



184 DISCHARGE, URETHRAL 

In spite of all forms of treatment, a slight urethral discharge occasionally persists, 
and the physician may be asked if any infection remains, or whether a patient may be 
allowed to marry. A chronic urethral discharge may contain gonococci or may be entirely 
free from any f)rganisms. Obviously, if any gonococci are found, the discharge is still 
infectious, but there is often difficulty in detecting the organism in these chronic cases, 
whilst in some they may be found if any slight exacerbation of inflammation occurs. 
Other cases again show a chronic urethral discharge which resists all treatment, but which 
ct)ntains a few pus and epithelial cells, though no organisms can be found. That pus cells 
are present in this small urethral discharge is no detriment to marriage, provided that no 
gonococci can be found, and in practice, if no cocci are found after irritation of the urethra 
by irritant injections, instrumentation, or the free use of alcohol, on several successive 
examinations, marriage may be permitted. 

.\ uretliral discharge may in rare cases be present in other conditions than that produced 
till iinnorrlid'a or septic urethritis, and as difficulty may arise if one of these cases be met 
witli. it is lueessary to mention them. 

Herpetic Urethritis. — The mucous lining of tiie urethra is undduliteoly affected by 
herpes in the same manner as other mucous membranes. fre<iuently as a tertiary lesion 
of syphilis. There is irritation of the urethra during micturition, and a slight muco-puru- 
lent discharge from the meatus. The small vesicles may be seen by the endoscope, and 
may be associated with hcr|Hs of the i)repuce. 

Soft Sores in the Urethra are distinctly uncommon. They occur in the terminal 
portion of the urethra, and cause painful micturition and a profuse, thin, purulent dis- 
charge, which contains no gonococci. There may be other sores on the glans penis, and 
an ulcerated surface will be sten on endoscopic examination. They occur within a few 
days of infection, and, if extensive, may produce narrowing of the urethra on healing. 

Syphilis may affect the urethra either as a hard chancre or as a gunmia. 

The Chancre occurs in the anterior end of the urethra, forming a firm indurated mass 
which can be felt readily on external palpation. The meatus is oedematous and swollen, 
so that the introduction of an endoscopic tube is impossible ; there is a thin, purulent, 
and often blood-stained discharge from the meatus. .V urethral chancre nmst be 
diagnosed carefully from peri-urethra! infiltration due to urethritis : the period of incuba- 
tion from the time of infection, the presence of small, hard inguinal glands, the occurrence 
of secondary lesions of .syphilis, and Wa.ssermann's serum test will ])oint to the diagnosis. 

(iunimata of the urethra give rise to a watery urethral discharge when they break down 
and cause ulceration. They may ulcerate through the canal and form fistuloe, but may 
u.sually be recf]gnized on careful examination. 

Papillomata of the Urethra may occur either in the anterior or posterior portion, 
as small, peduiuulated tumours in the canal, and frequently as a sequel to a chronic gonor- 
rhoea. They may arise, however, in the urethra of a patient who has never had urethritis. 
They cause a thin, scanty discharge, which does not yield to injections ; they are seen 
readily through the endoscojje. 

Carcinoma of the urethra is very rare as a primary disease, and in the few cases 
recorded has been in association with stricture. It forms a tumour in the urethra palpable 
from the exterior, and causes painful micturition with a blood-stained discharge, and 
enlargement of the inguinal glands. Suspicion of carcinoma should arise if a hard, irregular 
tumour be felt in the course of the urethra, without gonorrha?al infection, in an elderly 
patient, but the final diagnosis depends on liistological examination of a portion of the 
growth. 

Tuberculosis of the Urethra is always secondary to disease elsewhere in the genito- 
urinary tract, usually of the jjrostate or seminal vesicles. 

Foreign Bodies in the Urethra may cause a jjurulent urethral discharge if they 
remain in the canal for any length of time. They may be introduced through the meatus 
by intent — matches, pins. etc. : or a piece may be detached from a damaged catheter : 
or a small calculus may come down from the bladder and be arrested. In the latter ease 
the history is usually clear — sudden stopi)age of the .stream of urine during micturition 
with penile pain : a calculus may lie felt from the exterior or seen through the endoscope. 

R. li. Jocelyn Swan. 



DISCHARGE. VAGINAL 185 

DISCHARGE, VAGINAL. — In order to recognize the varieties of pathological vaginal 
discharges, it is hrst important to realize what the normal secretions found in the vagina 
consist of. The secretion normally present must he a mixture of those from the uterine 
body, cervix, and vaginal wall. That from the uterine body is watery and small in amount, 
whilst that from the cervix is thick and mucoid, but clear and transparent, like imboiled 
white of egg. The vaginal secretion is merely a transudation of plasma from the vessels, 
mixed with descjuamated vaginal epithelium, and in virgins looks like imboiled starch 
mixed with water. Naturally it is very small in amount. The bulk of the secretion found 
in the vagina comes from the cervix, because there are far more glands there than in any 
other part of the genital tract. 

The secretion from Bartholin's gland, which is thin and mucoid, may be cojjious under 
.sexual excitement, but under normal conditions is absent, and so does not contribute to the 
secretions in the vagina. The vaginal mixed secretions are acid in reaction, owing to the 
presence of lactic acid produced by a long bacillus which is found normally in the vagina. 
On the other hand, the unmixed uterine secretions are alkaline. Normally, the amount 
of mixed vaginal secretion should do no more than just moisten the vaginal orihee. When 
the amount is so great as to moisten the vulva and consc(|uently stain garments, the 
secretion is pathological. 

The composition of an abnormal secretion varies considerably according to the source 
from which most of it eomes. The commonest type is the thick white or yellow discharge 
associated with infiammatory changes in the cervix. It contains a large proportion of 
mucus, many leucocytes, masses of shed epithelium from the vagina (• squames "), and 
bacteria of various kinds. This is quite typical, and is produced by eiidocenicitls and 
cervical erosions of the various kinds. \Vhen, however, there is a corporeal endometritis 
present as well, the discharge becomes thinned, white, or yellow, on account of the admixture 
of much watery secretion from the body of the uterus. The yellow colour is due to the 
admixture of red blooil coriniscks. and in some cases the fluid may become actually blood- 
stained. Menorrhagia accompanies these discharges and serves to distinguish a mixed 
corporeal and cervical endometritis from a simple cervical catarrh. Micro.scopically the 
films made from the mixed cases show proportionately less mucus, but otherwise the 
constituents are the same. 

Vaginitis rarely exists alone, but when it does occur the discharge is thick and ])asty 
if it is a simi)le catarrhal condition : pasty on account of the large admixture of destiuiimatcd 
vaginal squamous cpithcliiun. On the other hand, in granular catarrh;. 1 vaginitis the dis- 
charge is nnich more |)urulent and eo|)ious owing to the exudation of more lluid from the 
exposed blood capillaries. This is the kind of discharge associated with traumatism of 
the vagina, especially from the irritation of badly-litting pessaries, and actual ulceration 
as in decubitus ulcers on prolapsed portions. Practically no mucus is found in such 
(liscliarges unless the cervix shares in tlie inflammatory process. 

'I'lierc is nothing characteristic it{ i;<inorrli(i-al (liscliarges to the naked eye or on simple 
microscopical examination. The detection of the gonococcus alone can decide the {jucstion. 
This is often a matter of great dilTicuIty. because it is only in the few days immediately after 
infection that the gonococcus can be found free in the vaginal discharge. In chronic cases 
llie gonococcus nnist be looked for in two places, cither the interior of the cervix or in the 
urethra and Skene's tubes, which open by the sides of the meatus urinarius. 'I'hc best 
plan is to take some discharge from within the cervix, after carefully wiping away discharges 
from the os uteri with stcriU' wool, using a Kergusson's speculum. This discharge should 
be spread on a glass shdi- :iiicl put by In dry. A second film on another slide should then 
l)c made, by sc|uee/.ing IIk' unlliia tnim liiliiu<l forwards and mojjping up any secretion 
thus nuidc to appear on the meal us. .\ftcr drying in the air the films should be li\e<l by 
l)assing tlirough a flame, and then stained by (Jrani's method, followed by neutral red as 
a counter-stain. In films prepared in this way gduococci are staiiu'd red whilst organisms 
which retain (iram's stain appear deep violet or black. The gonoeoeei arc usually found 
in the cytoplasm of the polymorphonuclear leucocytes (Plate XXl'1 1 1, p. (ill). 

Offensive smelling vaginal discharge is associated with decomposition, and it may be 
that the discharge itself is decomposing because it cannot escape fast enough from the 
passage, or that the source of the discliargc is a decomposing substatu'c like a slonghing 
jiliroiil i\r tii'crolic iiuciiiiinia of the irni.r. In the I\mj lullcr cases llic discharge is copious 



186 



DISCHARGE. VAGINAL 



watfi y. aii'l blood-stained, with a horribly foetid smell. When the discharge itself is decom- 
posing, it is usually thicker and purulent, and is commonly retained by pessaries or by 
redundant folds of vaginal mucous membrane. In old women a foul discharge may come 
from the interior of the uterus, a pyometra ; in which case pus can be made to flow from 
the OS uteri by squeezing the uterus or passing a sound. It is due to senile endometritis. 
the result of infection, and is often associated with cancer of the body of the uterus. 

Watery blood-stained discharge, not offensive, occurs in cancer of- the Imdij of the nter)is. 
in early cancer of the ceri'ix, with mucous polypi, placental poUfpi. and hi/datidifonn mole. 
The differential diagnosis of these conditions cannot l)e made from the discharge alone, 
hut must rest upon physical examination combined with the use of the microscope upon 
materials removed from the uterus. 

J'dSiiiiil casts may be composed of coagulated surface epithelium, the result of 
astringent injections or ap|)lications. and are easily recognized with the microscope. 
Membranous flakes may be passed with discharge in cases of membranous vaginitis. They 
consist of vaginal epithelium entangled in coagulated blood plasma, and present quite a 
different appearance to casts of coagulated epithelial layers. These membranous masses 
may be seen lining the whole vagina, and are generally due to special organisms. The 
diphtheria bacillus (Plate XXl'llI. y. (iH) has been found to be the causal agent in such 
cases, and in one investigated by the writer, the Bacilbis coli coniniiinis was the offending 

T. G. Stevens. 



organism. 




DIZZINESS. (See Vehtigo. p. 751.) 

DOUBLE VISION.— (See Diplopia, p. 174.) 

DROP-FOOT.— (See Par.\pi.egia, p. 510 ; 
and Pahai-isis of One Extremity, Lower, 

p. 4!Hi.) 



DROP-WRIST.— (See Atrophy, Mvsctlar, 
DROPSY. (See a:DEMA, II. 411.) 



DWARFISM (Microsomia, Nanosomia). — For 

purposes of diagnosis, dwarfism may be divided 
into two classes, namely, dwarfism the result of 
deformity, and divarfi.^tn without deformity. Gener- 
ally S])eaking, well-proportioned dwarfs owe their 
defective stature to a generalized delay or arrest 
of development, and are therefore in a .state ol 
infantilism, whereas deformed dwarfs are stunted 
in growth only, though the reduction in height 
may be due rather to the warping or collapse ol 
the bony framework than to actual curtailment 
of height. 

I. DWARFISM THE RESULT OF DEFORMITY. 

This kind ol dwarlism is due mainly or solely 
to shortness of the legs. In most cases the primary- 
fault lies in the skeleton, but occasionally the 
dwarfism has its source in deficiency of the brain. 
and still more rarely is brought about by a local defect of development implicating the 
lower extremities. 

A. Skeletal Dwarfism is occasioned by : — 

(1) Rickets; (2) Achondroplasia; (3) Osteogenesis imperfecta: (4) .Anosteoplasia ; 
(5) Osteomalacia. 

Rickety Dwarfism (Fii;. 85) is usually moderate in degree, and is due partly to actual 
shortening of the bones of the lower limbs and partly to bending (bow-legs or knock-knees). 



s mink-i-atc, .ind 1= due to biMLdu« and sliorteiung of 
tlie thigh and leg bones. There is knock-knee, tlie 
tibiae are sabre-shaped, the feet flat. ' The wrists and 
ankles are large ; the muscles are not affected. 



DWARFISM 



187 



It may also be the outcome of antcro-posterior or of lateral curvature of the spine. The 
skull looks big and is of the square or hot-cross-bun type, with bulging ferehead. The 
shape of the nose is not affected. There is often a pigeon breast or a transverse groove 
round the lower part of the chest (rickety girdle. Harrison's sulcus), and an hour-glass shaped 
or. at times, beaked (rostrate) pelvis. The nuiscles arc well-developed, and the body is 
scjuat and thickset. 

In Achondroplasia (Fig- 86) the limbs are shorter than in rickets, and the stature 
less. The ijrojjortions are of the dachshund pattern. The shortening of the limbs is chiefly 
of the i)roximal segment, and the body, though actually short, is relatively long. The 
legs are often bowed, and there may be bending of the upper limb bones. The joints are 
usually prominent. The forehead is bulging, the bridge of the nose depressed. There is 
conspicuous lordosis, and the pelvis is small and contracted. The muscles arc often dis- 
proportionately big, giving the achondroplasic a sturdy appearance and a surprising degree 
of strength. The fingers are broad, the three middle lingers being of equal length and 
divergently curved. 





i>>. ^i; \.l iv^ill. -.\KO 1.-.. -I'l..- run, I i- .1- 

1 ..I ,..l !. ■. Mh, und the liiiil.- >■ n ',■■,! n.- 

-Hh il I ■ Imiii.-i- than the rlb^tiil < :im i I ^"■ 

111-.- .1 .r-i'.l. ami the fore:inri- m.l I.- ,r.- 

eel. The M.isi. is ilelk-icnt at the l.n.l-.'. In thi, 
: there Is infuntilLsm as well as dwarlisin. 



Fifj. S7.— O^teotre-iesis itnperfeL-tJi. — 
As;e ;iJ. lietidiiifl of the tiliuu, femora, 

tinned for nearly ten vear> before it 
TOLted. There «.is no' .-idl'LyMid en- 



Osteogenesis Imperfecta (osteopsathyrosis, fragililas ossium) (/''/f. S7) is cliaracteri/.ed 
l)\ lirilllciicss Willi sdtlciiinir. Then- is not iimcli dwarling. cxccpl as the result of the 
ylcldinu of the lidiics. :iiiil llic niiiscles are usually weak. The disease piobably somelimes 
runs on iiilo iisli-nnialacia. 

Anosteoplasia, m- cleidd-ciaiiial dysostosis. Willi Miiicnil iiiipiiiirnciil (.1 Ikhic grciwl h. 
causing moderate dwarfism, there is pronounced deled in llii' IoiiikiI Ion ol llie lueiiibrane 
bones. The skull is romidcd and broad, the face small, the dcnlilioii dchiM-.l ; I lie clavicles 
are riidiiiieiilaiy or absent. The disease is often liereililarv . 

Ill Osteomalacia the dwarfism is due almost solelv to the eriimpliiig ol llie decalcified 
lioiies : hill uhcri Ihe disease occurs in childhood Ihere is also some dimimilion of stature 
ti-oin aii-esl ot hone mowlli. The muscles are eoiispieiiously weak. 



188 DWARFISM 

DiagtMsis of Skeletal Dwarfism. — Though osteojjenesis imperfecta, rickets, and achon- 
(Intplasia can, as a rule, be distinguished readily one from another, eases occur in which 
one of these diseases seems to blend with another, or at any rate to partake of its characters. 
In distinguishing rickets from achondroplasia it must be remembered that the most char- 
acteristic features of rickety dwarfism are the bending and the post-natal origin, and of 
achondroplasia the shortness of the limbs (micromelia) and the pre-natal origin. The 
enlargement of the ends of the bones which is so distinctive of rickets disappears as the 
disease settles down and the bones continue to grow, whereas in the hyperplastic form of 
achondroplasia it remains throughout life. Extreme softening must cause us to suspect 
osteogenesis imperfecta or osteomalacia, even if there are rickety enlargements as well, 
especially if the bending continues to increase after the age of six years. 

Dwarfism may be due solely to spinal curvature. If a kyphosis it is usually the result 
of tuberculous disease (caries) of the spine, but is occasionally a local manifestation of 
rickets, or possibly of osteomalacia. When of rickety origin there is not only kyphosis of 
I lie dorsal region, but a compensatory lordosis of the doi'so-lumbar. If it begins in middle 
or old age it is usually osteoarthritic, but as a rare event it may be due to osteomalacia 
.(o. senilis). In the latter event the softening is usually confined to the spine and pelvis, 
and may take place with extraordinary rapidity, and be followed by gradual hardening 
and fixation in the deformed position. 

Scoliosis is usually of mixed origin, the main factor being an inherent laxity of tissue 
showing itself in weakness of the back muscles and of the spinal ligaments. This laxity is 
supplemented by faulty i)ositi()ns of standing, sitting, etc., or by the injudicious use of 
stays. But it is |)rohabk- tliat siiinal curvature of sufficient severity to produce dwarfism 
is invariably the result either of rickets or. in rare cases, of a mild and local form of 
osteomalacia. 

li. Cerebral Dwarfism. — This form of microsomia is most jironounccd in niicroceplial/i. 
but hydroicplialy. porencephaly, imbecility, or any degenerative cerebral affection of early 
progressive development may be associated with puny growth. The microcephalic dwarf 
is characterized not only by the relative sniallness of his head (circumference never exceed- 
ing 17 ins.), but also by his sloping forehead, projecting nose, and receding chin, giving 
him a ferret- or rat-like physiognomy, lie is usually (piiek of movement, and restless, 
and is either imbecile or idiotic, accor.ling to the degree of his microcephaly, 

C. Dwarfism from Pre-natal Deficiency of the Lower Limbs. — This is of two 
kinds : phocnmehis and ectrt)melus. In pliocoinclus the defect is in one or both of the 
l)roximal segments, leaving the hands and feet unalleeted. so that the individual affected 
resembles a penguin or a seal (jjhoea). In eclroineliis there is absence of ]jart or whole of 
the limbs from the feet up. 

II. DWARFISM THE RESULT OF DEFECTIVE GENERAL DEVELOPMENT. INFANTILISM. 

Well-proportioned dwarfs are not invariably of backward development, for we meet 
with men of excellent development, who, if not actual dwarfs, are so dwarfish in stature 
that we have to admit the possibility of the existence of a true dwarfism in which there 
is no infantilism. Xevertheless, generally speaking, the dwarf of correct proportions is 
affected with infantilism. 

To Distinguish Infantilism from simple Dzcarfism. — Dwarfism is a defect of growth, 
whereas infantilism is a defect of development. In determining whether development is 
implicated, stature, ossification, and sex development are of great but not decisive import- 
ance. Thus infantilism may co-exist with gigantism ; and the ossification in some cases 
of symptomatic infantilism is not only not delayed, but may be actually premature. It 
is also prematme in progeria. Moreover, a sexually mature child of five or six does not 
cease to be a child because its ossification and sexual condition resemble those of an adult. 
Evidently therefore neither height, nor sex, nor ossification is a cardinal feature of 
infantilism. Indeed, in some cases of sexual ateleiosis the presence of infantilism is 
determined by the child-like stature. |)ro|)orti(>ns. and physiognomy alone, the individual 
being in all other respects a well-developed human being. 

The F(n-ms of Infantilism. — Infantilism may be widespread among whole races or 
nations (racial infantilism), or may select certain individuals or families, and occur 



DWARFISM 



189 



epidemically or sporadically as morbid infantilism among people of ordinary development. 
Morbid infantilism is of two sorts, namely, symptomatic, the result of causes : and essential, 
or crvi)tosenctic. 

A. Symptomatic Infantilism. 

This is seldom or never of extreme degree, has no uniform type of physiognomy, and, 
being an ac(|uired condition, is never transmitted. It is best classified according to the 
nature of the cause by which it is produced. 

It may be the result of intoxication with the poison of syphilis, wine, tobacco, or with 
that of rheumatic, scarlet or other fever, or with lead. Herter claims that the intoxication 
may arise from over-abundance of the normal flora of the intestine (intestinal infantilism). 

It may be the result of correlation, as when it is associated with kyphosis or with 
splenomegaly, or with liyprrtrophic cirrhosis of the liver. Perhaps the best example of this 





uniform and extruiiic. Tlie intclliu'<;iicL-. piuiiui iinii. . 
attitude, muniicr, correspond witli tliose of n L-liild ol 
18 moiitlis. The features are pulTcd and. disfigured 
U'itll the ciianieteristie pseudo-(Pflenm. 



Idiin (if iiilaiil ilisni is Ihal wliicli is a-siieialcil wilh iiiicnin iiiidly. In sdinc inici'occphahc 
dwarls llicrc is mil only an iinpaiiiiicnl ol' giduih, cunslitiitiny dwarllsm. hut Ihc dexilop- 
nii 111 ol the whole body is stayed, apparently because it is the custom for a certain develop- 
incnl of the body lo go witli a {•ertain size of Ihc brain, and such cusloins are liable to be 
Miainlained cxcn under abnormal condilioiis. Dwarfs with <liininulive heads may be of 
JMsl proportions and ol fairly good intelligence, iirovided the growth of the body is so 
I'ctarded that it remains in keeping wilh the growth of the brain. In thymic infantilism 
IlLcre is fatness with anuiiiia. and liability to syniopal attacks, which often end in (h'ath. 

It may be dn<- to the (h'/iciciici/ of ii hormone which oidinaiily stinmlalcs development, 
'riici-e are two forms : («) Tliyroid. .and ih) i'itiiilary. 



190 



DWARFISM! 



Thi/rokl infantilism in its most characteristic form — cretinism (Fig. 88) — is unmis- 
takable : but cases of infantilism occur in which the physiognomy, stunting of growth, 
and backward sex development suggest mere thyroid inadequacy. Some reserve the name 

of thyroid infantilism for these cases of 
■ myxccdeme fruste,' but the term should 
only be applied when the intelligence is 
defective and imiform improvement sets 
in as the result of giving thyroid extract. 
The tliyroid inadequacy may however not 
be primary, but a mere incident in some 
other form of infantilism, e.g., ateleiosis. 

In Piliiitdry infantilism (Froelich's 
syndrome. Fig. 8t)) there is fatness with 
conspicuous genital backwardness as well 
Fuj. wj.- M..! j.oin, \j. II Hi.- ueiicrai dPi-fiii|iTiir.iit as a gcucral defect of development. 
Lm S|:.n!i : ": ; :' u "-I,,!" „ r'S'S^ifeS rSS?1^ Polyuria or glycosuria is often present, an.l 

flat. The i.n i . ,i 1. iniii. i ii.. thcrc may be drowsiness or nutrition:;] 

changes in the skin and its appendages. 
Sickness, headache or otlier symptoms of a cerebral tumour are occasionally present. 

Mongolism {Fig. 9(») is distinguished from cretinism or myxoedeme fruste by the pre- 
dominance of the imbecility as compared with the slightness of other cretinoid symptoms. 
In reality the physiognomy is only cretinoid because it remains of the infantile type. It 

is not disfigured by the thick lips and general 
pseudo-oedema of cretinism, and the tongue, 
though sometimes protruding, is not large. 






FiG. 111. — Aiiansioplastic infantilism. — -\2e It;. 
Tliere is general delay of development, but not to an 
extreme degree. The physiognomy and proportions 
are of tlie adult pattern, but sc.v development is 



i-hil.h-li. 
developi 



A liov of twelve with asesua 

■ niial boy of six. His heiglit, 

i\-ioi.'nomy are conspicuously 

lii-^t. hilt in reality his trunk 

uinal type. 



DWARFISM 



19) 



The eves remind one of the obliquely-set eyes of the Chinaman, but it is sometimes 
difiieult to make out the resemblance. The ligaments are lax. and niongols are liable to 
become ;knock-kneed and to have " double-jointed ' thumbs. There is often some 
valvular afleetion of the heart. 

In a given case of infantilism it may be impossible to say liow much is due to correla- 
tion, how much to intoxication, how much to hormonic deficiency, and hew much to mere 
lack of luitrition. This may be said. e.g. of cardiac, or arterial, of renal, and of pancreatic 
mfantilism. 

('(iiflidc infantilism exists when there is some dominatini; incapacity of the cardiac 
valves. Sometimes there seems to be a deficient development of the whole arterial 
.sy.stem. constituting (inangiophislic infantilism [Fig. 91). 

In paiirrentic infantilism there are 
indications of pancreatic incompetence. 
The stools are fatty, copious or frequent, 
pale and offensive. Capsules of iodoform 
enclosed in a glutoid envelope (Sahli"s 
capsules) are soluble only in the pan- 
creatic secretion, and are therefore not 
dissolved in this form of infantilism. 
The iid'antilism is improved by pan- 
creatic extract. 

Renal infantilism is consecutive to 
chronic Bright "s disease, and is suggested 
when there are polyuria, albuminuria, 
or other symptoms of Bright's disease, 
and no indication of a ])rior syphilitic 
or other intoxication. 

I}. Essential or Cryptogenetic In- 
fantilism. 

This is distiiiguisluil from symjitom- 
atic infantilism by its pronounced degree, 
by its seemingly s|)oiitaneous appearance, 
anfl occasionally by its heredity. There 
arc two forriis : rtleleio.si.s- anrl iirogiria. 

.ItelviiiHis (Fig. 02) is primary, spon- 
taneous iid'antilism. H may begin at 
any age <if progrcssi\<' development, and 
its eharacti'rs arc for I lie most part those 
normal to the ag'- of its first a,|)pearanec. 
It usually begins in infancy or earlN 
childhoorl, and the ^i/,c. priiportidiis. and 
physiognomy of this lime of lil'c arc 
pcr[)etuate<V It is pmrir to he associ- 
ate<l with c'rv|)torchism. or \\\[\\ some 
cctrresponding ill -<levelopMi( iil of the 
ovaries, causing divergence into two 

varieties, sexual and asexual. In iisv.niiil itteleiasis all llic physical fcalmcs of inlantile 
life are stcreotypiil : Iml in sfiiial nlr/riasi.'i. though the physiognomy and ])ro|)ortions 
remain intantile or (•liilclish, Ihc orisci ol piibcrtv (often greatly delayed) brings with it 
some accession of growlli and Ihc Mcldllioii ol Ihc |iriiniii\ and sccoiidarv sex characters 
<.f Ihc adult. 

J'logerifi (Fig. MM) is priiiiaiy. spontaneous infant ilism mingled with premature senility 
(senilism). Hence, with shortness of stature and other indications of infantilism, there 
are baldness, emaciation, arterial sclerosis, and general decrepitude. Death from angina 
pectoris or oilier senile disease may ensue at IS or even earlier. Ilnsliiigs (iilford 

DYSARTHRIA. (See Sim;i;cii, .Aunoiimai itiks ok, p. (i2(i.) 

DYSCHEZIA.- (See CoNsriCAiioN. p. I-j.) 




Ill yrey 



,.|.i|,l,; 



DYSMENORRHCEA 



DYSIDROSIS. -(See Swi.ATiNc. Abnormalities of, p. 654..) 

DYSMENORRHCEA owes its origin to a variety of causes, wliich must be differentiated 
carefully iu order tliat treatment may be successful. The following table presents the 
causes of the three common varieties : — 



1. Spasmodic 
Congenital malformations 
Deficient uterine muscle 
Long conical cervix 
Stenosed external or inter- 
nal OS 
Neurasthenia 



2. Congestive. 
Endometritis 
Uterine congestion 
Retrci\ cisiiin ami flexion 

Silll.lir-n-,.,.|,l,,,ritis 

Pelvic peritonitis 
Small cystic ovary 
Neurasthenia 



3. MembranoU! 



The distribution of the cases into these three classes is often easy ; in the iirst place, 
because spasmodic cases are practically always priniary. that is, they commence with the 
onset of menstruation ; whilst congestive and membranous cases are secondary, that is. 
acquired as a result of some definite lesion. Further, the nature of the pain is often char- 
acteristic of the type of case, for in spasmodic cases the pain is intermittent, griping, and 
■ colicky,' commencing at the same time as the blood-flow, or only just before it. In 
the congestive cases, on the other hand, the pain is continuous and aching, and begins 
some hours or days before the flow. In typical eases also this pain is relieved by 
the flow. In the membranous cases the nature of the pain partakes of the characters of 
both the former types, being aching and continuous first : then becoming colicky and 
spasmodic when the uterus is attcm])ting to expel the characteristic membrane or cast, 
and being finally relieved when this comes away. Many cases are met with in which the 
])ain partakes of the nature of both the congestive and spasmodic types. This usually 
means that a woman who originally had spasmodic dysmenorrhoea acquires some lesion 
which in its turn gives rise also to the congestive tyiJc of pain. 

Having scttlcii that a case belongs to one of the three main types, it is not very difficult 
lo work out the actual causation. This is more difficult in the spasmodic cases than in tlie 
congestive. Ijccause the latter depend upon well-defined lesions, and the former do not. 

Spasmodic Cases. — The causation of this type of case is often obscure ; but a bi- 
manual examination, or a recto-abdominal examination in virgins, will usually reveal a 
condition of the uterus which can only lie described as a congenital nialformntion. It may 
be small, but of the adult type : it often has an exaggerated anterior bend, the ' cochleate ' 
uterus of Pir/.zi ; and. in addition, the vaginal portion of the cervix is often too long, with 
a conical slia])e, and a \'ery small pin-hole external os. Into such uteri the sound may 
pass with dilficulty, owing to stenosis and rigidity of the internal os. The underlying true 
cause of the ])ain, however, is commonly admitted now to be imperfect development of 
the uterine muscle, in itself again a congenital malformation of texture occurring in an 
organ whose external form also is malformed The muscle being imperfect it is also possible 
that the ciKkunetrium is abnormal in these cases, unduly fibrous perhaps, and resistant : a 
l)oint which our present knowledge does not prove or disprove. One proof, however, of 
the truth of these views is the effect of pregnancy and labour on such cases. They are 
nearly always cured, owing to the great muscular development during pregnancy, and 
the extreme stretching of the lower segment during labour. Neurasthenia also colours 
and increases the ])ain in these cases ; but. by itself, will not start a spasmodic any more 
than a congestive dysmenorrhoea. 

Congestive Cases. — It is unnecessary to dilTerentiate the congestive cases as tubal, 
ovarian, or uterine, because the underlying cause in all is uterine congestion accompanying 
such lesions as are shown in the table. The differential diagnosis of these lesions is to be 
made by a careful consideration of the history, combined with bimanual examination of 
the pelvic organs and, if necessary, curettage of the uterus, which also serves to cure the 
cases of pure endometritis. Cases due to endometritis are to be recognized by the cardinal 
symjitoms of this lesion, namely, menorrhagia, Icucorrha'a, often blood-stained, and chronic 
backache. These symptoms accompany slight enlargement of the uterus without any irregu- 
larity in shape such as would occur if fibroids were present. Simple retroversion and flexion 
can be recognized on bimanual examination : the fundus will be felt posteriorly, the cervix 



DYSPAREUNIA 193 

lo(jking directly down the vagina in a forward direction. Solpingo-ooplioritis in its typical 
clnonic form gives rise to irregular very tender swellings on either side and behind the uterus, 
sonietiines forming definitely retort-shaped swellings, especially if ])us is present in the tubes. 
Fixation of these swellings and of the uterus is a very diliniti' sign of the disease ; whilst 
the history of one or more attacks of acute illness, with pelvic pain, will assist to make the 
diagnosis certain. The small cystic ovary may exist without obvious salpingo-oophoritis, 
and without widespread fixation. The ovary is foimd to be permanently enlarged and 
irregular in shape from the projection of cysts from its surface. Neurasthenia is included 
imder this heading because any menstrual pain is made worse by it, and only a very slight 
lesion need be present for this nerve weakness to accentuate any pain arising from it. 

Membranous Cases. — The membrane, or cast, is of two types, and is easily recognized 
and distinguished from other uterine casts, such as those formed by the decidua of preg- 
nancy. The classical cast of membranous dysmenorrhoea is hollow, triangular, not more 
than one-eighth of an inch thick, and possesses three openings. This, however, is not the 
common form ; for in most cases the cast is solid, and formed by the mucosa being rolled 
upon itself. Tliese casts contain connective-tissue cells and uterine glands in a stroma 
which is crowded with leucocj'tes. The solid cast may be nearly half an inch thick, and 
looks microscopically as if it were composed of endometrium into which haemorrhage and 
Icucocytic infiltration had occurred. The glands in it are broken up, and often lie on the 
outside. These casts never contain any compact masses of large cells of the decidual type, 
but an occasional hypertrophied connective tissue cell may be foimd. Decidual casts, on 
the other hand, are the result of pregnancy, and consist of compact masses of large poly- 
gonal cells without any fibrillated connective tissue. They contain glands with hyper- 
trophied e])ithelial linings, and often show large hiemorrhagic foci. The occasional (Jresence 
ill I hem of chorionic villi absolutely settles the diagnosis. 

It must not be forgotten that cases of dysmenorrhaa may be mistaken for those of 
alxlominal pain due to other lesions unconnected with menstruation : and the differen- 
tiation of such cases may be a matter of considerable im])ortanee. It is conceivable that 
dysmenorrlio-a mav be mistaken for : — 



.■\pi)en(lieitis 

Colic, intestinal, renal, i>r hepatic 
Perforated gastric ulcer 
l{ii[)turcd tubal gestation 



Torsion of an ovarian cyst ])edielc 
Haemorrhage from or into a Graali:iii Inlliek' 
Rupture of an ovarian cyst or pyosalpiiix 
Dyspepsia with tlat ilent distention. 



Obviously, sonic of these lesions are dangerous to life, and therefore it is essential that 
lliiv be not oNcrlookcd. The danger of this oci-in-ring is inenased if any of these lesions 
stint Ml or near the expected time of a menstrual period, and would hardly arise at all if a 
nKiisliMal period had taken place recently, or was not expected for some days. It will 
be iioUii that all these lesions are accompanied by stulden abdomimd pain, which might 
piiliaps lead lo a suspicion of spasmodic dysnicnorrlKCM, bill hnrdly of eongeslixc, owing 
lo I lie cliaracler ot llic pain. 7', (!. Stevens 

DYSPAREUNIA, or painlid coitus, may depend im a varicly of local Icsidiis which 
rcipiirc carf'tnl ilillcicril iation for their approprialc trcatnu'nl, or il may <-xisl when no 
local lesion can be luund at all. It is associated <'losely with vaginismus, or paiid'ul spasm 
of the levator ani ninsclc mi atlciiipts at coitus, and the same lesions which cause sim])le 
dysparciinia may also give rise to vaginisnuis. It is remarkable that in sonic women a 
small Inciil lesion will produce no pain upon attempts at coitus which in anollicr will cause 
pain accompanied by \iolcnt spasm of the levator ani. In some cases pain arises because 
there is a dillieulty of penetration of the vaginal orifice, whilst in others there is no dilli- 
ciiltv. but pain is caused. The lesions which cominoidv give rise to dvsparcimia .ire (lie 
following :-^ 

('nii^rcMital uhseiice of llie Xciiiil is oil lir puliic mii\ c Cliniiiic iiicl lilis 

Inwi-r p;iil (if llic \:i-iMii llcalcil pciiiMal laccraliniis .S:il|iiiiL;ci-i"i|ilini il is willi 

liiiiipliiicil liviMcii ficlliiMl caiNMili- adiicsiuiis 

iMllaiiicI liviiiciiial iirilicc ficlliiilis Aii.il lissiiic 

\lllvilis Cvstitis ■|'lll(lllll,(.SC-li MIhI illllllllllMl 

li:iilli(iliiiilis I'njhipscii Iciiilcr iivMiirswilj, piles 

l..iiUti|,hikic Milvilis ic(ni\-ciled iileiiis 

Kiiiiiiusis \iilva' 



194 DYSPAREUNIA 

It will be noted from a perusal of the above that the lesions fall into natural groups, 
according as the situation of the lesion is at the vuha, the uterus and ovaries, the urinary 
passages, or at the anus and rectum. Consequently it is necessary to carry out a detailed 
examination of any case of dyspareunia in order to find out whether any of these well- 
defined lesions are present. 

The commonest lesion is certainly inflamed hymeneal remains, very often gonorrhoeal 
in origin and accompanied by redness and swelling of the orifice of the duct of Bartholin's 
gland. The lesion is self-evident on inspection, and the parts are acutely sensitive to the 
least touch. Leukoplakic vulvitis is a lesion that is obvious from the whit«, sodden 
appearance of the labia minora, and causes pain on account of the sensitive cracks and 
fissures which accompany it. Kraurosis vulva causes actual contraction of the vaginal 
orifice, and consequently penetration is difficult and causes pain. The red projecting 
growth from the meatus urinarius, earuncle, is self-evident and acutely tender, whilst 
urethritis is diagnosed by tlie issue of pus on squeezing the urethra. Cystitis is diagnosed 
l)y the presence of pus and mucus in the urine, accompanied by frequency of micturition, 
and it causes pain because the bladder is painful in such cases and intolerant of the 
disturbance caused by coitus. Puclic neuritis is not a well-defined condition, but can be 
recognized by tenderness along the piidic nerve just inside the vaginal orifice, where the 
nerve passes along the inner side of the ischial ramus. In prolapsed tender ovaries and 
backward displacements there is no pain on penetration and no dilliculty, but coitus gives 
acute pain. The condition is recognized by a bimanual examination, the same remarks 
apijlying to salpingo-oophoritis. bearing in mind that there is usually a history of some 
acute attack of pelvic peritonitis in such cases. In chronic metritis the tubes and ovaries 
may be normal, but the uterus though normal in position is tender to the touch, and 
consequently coitus causes pain. Anal fissure, thrombosed and inflamed piles, can only 
be recognized by a careful examination of the anus and rectiun by the finger and speculum. 

In the cases which occur without local lesions the vaginal entrance will be found to 
be hj'persesthetic as a rule, and penetration is- impossible. Such cases are almost always 
accompanied by spasmodic vaginismus. The most careful examination fails to demon- 
strate a lesion in such cases, and they are usually termed ' neurotic ' for the want of a 
better term. Such cases do not necessarily mean absence of sexual desire ; on the con; 
trary, many such patients are desirous of the consummation of marriage. Enlarging the 
orifice, or even child-bearing, does not cure a true case of this nature ; it must be in sonre 
way a disorder of function of the nerve centres. These cases must be distinguished from 
those in which the underlying factor is absence of sexual desire and actual dislike of the 
sexual act. Unhappy and imsuitable marriages conduce to this state of affairs, and the 
patient is liable to complain of pain when dislike is really what is meant. There is no 
difficulty in penetration in such cases. T. G. Sleveiis. 

DYSPEPSIA. — (See Indigestion, p. 315 ; and Flatulence, p. 240.) 

DYSPHAGIA literally means difficulty in swallowing, but the term itself does not 
indicate whether the dilliculty is mechanical, nervous, or due to pain : there are conse- 
(|uently several entirely different groups of cases, to each of which the term dysphagia has 
been applied : — 

1 . Dysphagia due to Mechanical Obstruction to the (Esophagus. — The usual 
history of ])rogiessive mechanical obstruct i(jn to the (esophagus is as follows : there is 
little or no pain, but the j)atient notices that whereas formerly lie could swallow anv'thing 
with case, he is beginning to experience difficulty with the more solid kinds of food, such 
as meat, dry bread, and vegetables, so that he is obliged to live mainly upon pulpy foods : 
milk puddings, gruel, and the like. Later he can swallow only liquids ; ultimately he 
liuds that even these are apt to be regurgitated soon after they have been swallowed, and 
there is often a sense of obstruction at some point between the level of the cricoid cartilage 
and the lower end of the gladiolus, which latter corresponds, as regards sensation, with the 
cardiac end of the cesophagus. When with the above history the patient gives a definite 
account of having swallowed some strong irritant or corrosive substance, such as an alkali 
or a mineral acid, the diagnosis of fibrous stricture from corrosive injury is easy. ^Vhen 
similar obstruction succeeds the swallowing o! nfineign body, such as a tooth-plate {Fig. U4). 



DYSPHAGIA 



195 



a large piece of bone, or a coin, the diagnosis is also easy as a rule, though in some 
cases there may he doubt as to the existence of a foreign body in the cesophagus unless the 
cesophagosco)3e is used, or the .i-rays employed with or without bismuth (Fig. 95). Where 
the symptoms are not directly attributable to anything of this nature, however, but come on 
insidiously, the diagnosis generally lies between squamoiis-celkd cnrcinonia of the cesophagus. 
cairiiioma of the stomach directly invading the lower end of the cesophagus. and aortic 

aiiciirijsm stenosing the oesophagus from 
outside. The actual fact of obstruction 
has first to be determined, and there is 
danger in passing a bougie unless aortic 
aneurysm can be excluded ; this exclu- 
sion is by no means easy, however, for 
that variety of aneurysm which is most 
liable to stenose the oesophagus is one 
atlecting the descending thoracic aorta, 
so that it does not give rise to any 
tumour, or pulsation, or bruit, and it is 
placed too far along the aorta to cause 
inecjuality of the pulses, inequality '^of 
the pupils (from interference with the 
cervical sym))atlutic), paralysis of a 
vocal cord (from interference with the 




J'i'j. 'J I. — Sudiiuii ilualli iruiii acute d!,ipiiu;a ; 
tootli-plute iinpjicted in tlie laryn.x. (From a < 
Warner lAimj. of Wmhrich.) 



Iclt 



I'liirciil l:nviit;( 
>r pain down 



tl THr\c). Ii-achcal liig- 
■itlicr arm. Tlic only 
other cITccts besirles ci'sophageal obstruction 
likely to be due to aneurysm in this position 
are: pain in the dorsal region of llii- spine, 
possibly ra»liating along the course ul (Mh- or 
more of the mid-dorsal intercostal ncrvcN 
towards tin- left, and ixrhaps obstruction to 
the lower part of the root of the left lung, 
causing impairment i>\ mile, of air-entry, or of 
voice sounds, willi or willjout some crackling HJ 

rales over the left lower lobe behind. If a "' 

bougie is passed, it should be a soft one, and 
extrenie care should be taken : but lh<' danger 
iniiy be avoided In towns where ,i-ray installations 
be demonstrated by making the p;itient swallow a eap> 
or barimn chloride and watching its course (Figs. it(i. it?) ; 
characteristic shadow in the i)osterior mediastinum. 'I' 
likely is it to be eareinoina ol' the (esophagus and not luu ii 
between primary growth of the (esophagus and iiihltralio 
starting at the cardiac end of the stomach, is ol'len one 




fui. 'J.>. -(I'.sopliagua blocked by a bean, which kIocs 
it show, but susi)eiids th(! bismuth food, the lower 
rdr-i- of which arches over the bean. As a result of 
e x-ra.v exainiiiHtiou the u'i^opluM^iLS was further 
plored atal the forelKn body removed. 

{.ik'iayram by Dr. C. Ttiurstan Holland.) 



I'Xlst 



. for the obstruction may ol'len 
iile or gruel containing bistmith 
while MM iiiiciirysm would east a 
II- oiiici- llic patient, the more 
r\sin. 'I'lie dilTercntial diagnosis 
1 of the (esophagus by a growth 
of great dillieulty, tmless there 



DYSPHAGIA 



liavc been definite gastric symptoms before flys])hiigiii set in. Secondary nodules would 
naturally be looked for, especially in the lynijihatic glands in the lower part of the neck 
and in the liver. A history of syphilis and c^•idence of syphilitic aortic regurgitation, 
especially in a man between the ages of forty and fifty who had been a hard manual 
worker and not teetotal, would render aneurysm probable. 

AVhen aortic aneurysm can be excluded, much information as to the nature of an 
oesophageal obstruction may sometimes be obtained from the use of an ocsophagoscope, 

and the latter can be used at the 
same time in facilitating the re- 
moval of such things as a foreign 
l)ody. 

Di/spliagia lusoria is a very 
rare condition due to compression 
<if the ct'sophagus by the right sub- 
clavian artery when it arises from 
the aorta beyond the left subclavian 
and passes to the right side either 
in front of or behind the oesophagus : 
the diagnosis in such cases will be 
almost impossible, though it might 
lie guessed at if there were other 
congenital deformities, such as club- 
foot or transposition of the viscera. 
(Esophageal pouches cause 
symptoms which can seldom be 
interjireted with certainty imless 
tlic case is watched for some time. 
IJencrally the patient can swallow 
with ease on some days, but with 
considerable difficulty on others : 
aneurysm, new growth, and trau- 
matic or corrosive obstruction to 
the oesophagus will be excluded 
partly by the residts of .r-ray exam- 
itiation and ])artly by the age — 
pouch cases are relatively young. 
'I'he point which suggests the dia- 
gnosis of a pouch is that the patient 
who has been able to swallow 
pirfectly well for a few days, and 
then begins to have difficulty in 
getting the food down, finds relief 
presently on the regurgitation — 
clearly not from the stomach but 
from some situation higher up — of 
a larger quantity of food material 
than had been swallowed innnediately before, including perhaps articles which were taken 
one or more days previously. The reason for these symptoms is that the pouch does 
not obstruct the oesophagus until it becomes very much distended by the gradual accu- 
nuilation in it of portions of the food swallowed, relief coming when the greatly distended 
sac em])ties itself back into the (isopluigus. 

•2. Dysphagia due to Nervous Causes without Obstruction. — The two commonest 
\arieties of dysphagia due to purely nervous causes are probably post-diphtheritic and 
hi/sterical. The former is characterized by regurgitation of the food through the nose, 
due to i)aralysis of the soft palate : inspection may demonstrate the flaccid condition of 
the latter ; there may have been a history of sore throat, of other cases of dii)litheria in 
the patient's neighbourhood, or Klebs-LofHer bacilli may have been found, or may still be 
found in the paticnfs throat. When regurgitation of the food through the nose develops 




Fiff. 9G. — Skiagram, af'era bismuth meal, sliowing the bismutli lifl'i 
III" by a malignant stricture of the cpsopha^us at about the level of the 
iiifiu-eatioii of the trachea. 



DYSPHAGIA 



197 



in a ijerson who is not known to have had diplitlieria, the symptom will usually arouse 
grave suspicion that diphtheria of a mild type has occurred but has been overlooked. There 
may or may not be other signs of peripheral neuritis, or there may be |)aralysis of the ciliary 
muscles of the eyes. 

Hysteria as a cause for dysphagia is familiar enough under tlic heading of globus 
hystericus, the diagnosis of which is not as a rule dillicult. especially if the patient be a 
young woman who has suffered from other functional nervous affections, for instance 
hysterical a|)li<inia. 

Less connnim varieties of dysphagia of nervous origin are : — 

liidlxir jKiralijsi.s; in which the 
characteristic and progressive dilKculty 
in the use of the lips, tongue, pharynx, 
and larynx point at once to the dia- 
gnosis, the only difficulty that may 
arise being perhaps in distinguisliing 
true bulbar j)aralysis, in which the 
lesion is in the motor nuclei of the 
medulla oblongata, from pseudo-bidliar 
])aralysis. where the lesion is due to 
bilateral cortical softening : in the true 
form there is atrophy of the tongue, 
in the pseudo variety the tongue does 
not atrophy, and chieHy upon this 
point is the differential diagnosis 
made. 

S !/j)li i I i I i (■ dciii' lie rat ion of the 
meilullary centres may produce syni- 
ploins not unlike those of ordinary 
bulbar iKUalysis. but it is generally 
<lillerentiated by the fact that other 
cranial nerves, particularly those of 
the eyeball, are probably affected at 
the same time, and there may also be 
evidence or ii clear liistorv of syphilis, 
with or without a |)Osilivc Wasscr- 
mann's reaction. 

Lead jioi.soniiifi and iiIiiiIidHsw may 
also be responsible for degenerative 
lesions affeeling the nerxcs concerned 
in the process of swallowing. 

deinrnl jiiiiiili/sis of llic iiismic 
iilliiiiately resiills In inability to swal- 
l<iw ; the s*vallo\ving rellcx is amongst 
I lie very last to disappear, and the 
diagnosis has long since been cstabiislurl ii| nllin- Lirouuds. 

Spanniiidic (li/sphogia. <luc to spasm of the nuiscular coals of the (esophagus and 
pharynx, is probably the cause of globus hyslerieus. but similar spasticity may prevent 
swallowing in much more serious diseases, and eonslilules a prominent symptom in 
lii/rlniidiiihid. in uliicli any ifl<irl to swallow licpiids producer the s\inpt<im in extreme 
jlegree. The hisloiy of a lioi; -bile as a source of contagion is the eliief point in arriving 
at the diagnosis. 

Mi/iisdiiiiiii finii-is is a \cr\- eliaraeterist ic <lisease. in wliicli I lie muscles tlial are 
alleiled are perlcctly abli' to do their wi)rk when they lirsl begin to e(intia<'t, but bicomc 
fatigued with great rapidity, so that after the lirst few eoni ract ions, those which succeed 
become less and less effectual, until they cease, and the alfccled nmscles will only be able 
to work again when tlies lia\c been given a long rest. 'I"hc neck nmscles. and those of the 
eye, larynx, and nioulli, hreome involved early (/''/X'. 111. p. 'I'A't). and dillicidly in swallow- 
ing after the first IVu r illifiils is sometimes a charai-tcrist ic li-atnic of the ease. The 




Fi'i. '.17. -Ski;m'nini 


Iiikoii in tlie 


selni-liitenil position nflor 


liisiiiiitli :i.hniiiistmtior 


ill a CMC of s 


oiiosis of tlie a-.sopliiii,'iis hv 


;x cariMiioiim at Uio ca 


(line oritice. 'I 


lie .liiii,-iiosis WHS vcriliuil lit 


subsenueiit operation. 


Tlie bismutli 


111.1 Imon t.iki-H -jn minutc'H 


previou.s to tiie .r-ray 


:;.\utniii.'itioii nii 


1 none liiul vot ontcrpcl tli(> 


stoniiii-h. 


( Sk-iii'/nnn It 


/ llr. r. Tliursliiii llnllaiiil.) 



198 



DYSPHAGIA 



nivasthenic electrical reaction (see Reaction of Degeneration, p. 584) serves to dis- 
tinguish these cases from those due to bulbar paralysis. 

Finally, there are very rare cases in which, without any known pathology, the 
oesophagus becomes enormously hypertrophied and dilated, and the patient cannot swallow, 
though a bougie passes perfectly well. This so-called idiopathic dilatation and hypertropliy 
of the oesophagus is fortunately very rare : it has generally been regarded as due to cardio- 
spasm — an erroneous spasmodic contraction of the cardiac orifice, which refuses to relax 
for the ingress of food into the stomach ; but a more recent view is that it is due, not to any 
extra spasm, but to defective relaxation of the normal tonicity — a condition to which the 
term (tclialini/i has been a])]ilied. It leads to dilatation of the oesophagus behind it. with 

much hyjjcrtrophy, the latter, 
great though it is, eventually fail- 
ing to overcome the neuro-muscu- 
lar constriction of the oesophageal 
spliincter, though bougies pass 
without difficulty. It may be recog- 
nized by tlic use of Ijismiith or 
barium and the .c-rays (Fi'<. 118). 
:>. Dysphagia due to Mechani- 
cal Defects of the Mouth or 
Pharynx, the CEsophagus being 
Normal. — This group of cases in- 
chidis patients suffering from such 
eondilions as widely cleft palate. 
syphilitic stenosis of the pharynx, 
inabihty to use the tongue, either 
because it • is acutely swollen from 
glossitis, bee-sting, or angina Ludo- 
\ iei, or because it is fixed from 
caieinomatous infiltration, and so 
fortli. There is little need to enter 
into the differential diagnosis of 
this variety of dysphagia, for it 
can generally be determined by 
direct examination of the buccal 
cavity. Mumps, quinsy, and post- 
pharyngeal abscess belong to the 
same group, the last-named caus- 
ing more dyspnoea than dysphagia, 
and being confined to quite earl\- 
childhood. 

t. Dysphagia in which there 
is no Mechanical Obstruction, but 
in which the Act of Swallowing 
causes the Patient so much Pain 
that he hesitates to Swallow. — 
The chief causes of dysphagia which come under this headinu are : Inlhimmatorv affections 
of the mouth or tongue, including the different varieties of .stomatitis (p. 542) : pemphigus 
or erythema hullosum of the buccal cavity, evidenced by similar eruption upon the skin 
(see BuLLiE, p. 96) : ulcers of the tongue, whether malignant, gummatous, tuberculous, 
or due merely to erosion by a carious tooth or an ill-fitting tooth-plate ; sore throats of 
various kinds (see Sore Throat, p. 613) ; pain in the mouth, larynx, or oesophagus after 
swallowing acute irritants or fluids that are either exceedingly cold or burning hot : and 
injhimmatory affections of the larynx and its immediate neighbourhood. 

The nature of the buccal lesions will generally be indicated by inspection. 
The different varieties of sore throat may be distinguished to some extent by inspection, 
though bacteriological confirmation is usually advisable. 

The chief dilHeulties arise when the cause of the dysphagia is a painful affection of 




medicines in tlio pliarnKicoyana," but wa:^ never vlia'^'nosed eorrectl3^ until 
bismuth and .c-ray examination was resorted to previous to a proposed 
gastro-enterostomy. (Skioffram by Dr. C. Thurstan Holland.) 



DYSTOCIA 199 

the larynx. Rarities such as variolous, lupoid, lejjrous, t^-jjlioidal, decubital, and trau- 
matic ulcers of the larynx will seldom be diagnosed imless there is obvious collateral evidence, 
such as the eruption of sniall-pox upon the skin, residence in leprous countries, prolonued 
conlinenient to bed, and so forth, to indicate the nature of the case. The commoner 
varieties of laryncreal trouble which produce dysphagia are acute laryngitis, tiiberculoua 
lari/i}gitis with or without ulcers, carcinomatous ulceration of the larynx, and syphilis. 
Laryngoscopic examination is essential, local anaesthesia by the use of the cocaine generally 
being necessary first. If tubercle bacilli can be found in the sputum, or if there are abnormal 
signs at the apices of the limgs, the diagnosis of tuberculous laryngitis is probable, and 
the pallid swelling of the aryteno-epiglottidean folds, and, still more so, multiple small 
ulcers of the edge or posterior surface of the epiglottis or of the free edges of the true or 
false vocal cords, or similar ulcers in other parts of the larynx, bilaterally situated, would 
indicate the diagnosis with certainty. The chief dilficulty arises in the more chronic cases 
ill which, after the larynx has become involved, the lung condition has improved, and 
tubercle bacilli may not be found in the sputum. F^pitheliomatous ulceration of the larynx 
may be very extensive, and yet for a long time remain confined to one side ; this unilateral 
distribution of the infiltration is often important in distinguishing epithelioma from syphilis 
(if the larynx, whilst the latter may also be distinguished by the repair which may ensue 
i\eii after extensive destruction of the tissues has led to much deformity of the parts. The 
inlluence of salvarsan or potassium iodide and mercury upon the lesions may assist the 
diagnosis, and Wassermann"s serum test may be employed. Doubt may remain, however, 
and sometimes, where it is very important to arrive at a certain diagnosis as soon as 
possible, a small portion of the affected tissue may be excised and examined microscopically. 
When tuberculosis, syphilis, and new growth arc excluded, and yet laryngitis is present, 
the probability is that it is due to some infecting organism. Probably the symptoms will 
lia\c started more or less acutely, even though they persist and become chronic ; laryngeal 
inspection may show acute hypera-mia and injection of the parts with extensive u-dema 
without ulceration, and the nature of the micro-organism concerned — the diphtheria 
bacillus, streptococcus, pncumococcus, etc. — may be determined baeteriologically by 
preparing cultures from local swabbings. It is possible, of course, for two or more maladies 
to occur simultaneously, and it is particularly difficult to distinguish syphilitic laryngitis 
from tuberculous in a syphilitic patient who has undoubted phthisis ; similarly, it may 
lie dilficult to distinguish catarrhal laryngitis from tuberculous in phthisical patients, and 
so on ; indeed, in many instances the diagnosis may be one of (ipiiiion only. Measles is 
very ajit to be accoiiipanicd by laryngitis, which ma\- often be merely (atairhal. but which 
not infrc(|iieiitly is due to fliphtlicria dcvehiiiiTig synchronously with the measles. In 
order to exclude diphtheria, it is always advisable to take swabbings for bacteriological 
investigation even where it seems almost obvious that the laryngeal catarrh is merely part 
of the gem nil coryza of measles. In all these cases dysphagia will be accompanied by 
hnaiNciuss or other alteration in the voice pointing to an affection of the larynx. 

Herbert French. 

DYSPNOEA, or marked dillicully or dislrcNs in lire alliiiig. mayor may not be associated 
x^ilh o^Hlo|^ll(l•a : in the iiiilder cases a patient when at rest has no dyspnoa. the dillicillty 
uitli breathing being brought out only by exertion : nearly all eoiiditioiis which may pro- 
duce dyspnua. however, are capable in later stages of producing orthopnoa. so that the 
causes of dyspn(pa and of ortlmpiiciM aic similar in kind though they differ in degree. There 
is no need, therefore, to repeat wlial will lie round under the heailing OiirnoPNa:.\ (p. U8) 
whilst the article on Hukaiii. Sikiium.ss (ii- (p. S7 ) sliould also be consultcel. 

UubrrI P'rineh. 

DYSTOCIA signifies diirKiill birth or labour. The dillieiilties of delivery show 
thenisiKis by pniloiigation or delay in llic cnniiilclion of the stages into which labour is 
usually di\ided. Dilliciilt labour is ac( iiiii|iaiiiiil by progressiNC symptoms, objective and 
subjective, which arc to be explained by physiological exhaiislioii. especially in its effect 
upon the central nervous system of the patient. The results of dilliciilt labour are thus 
of such importance, affecting, as IIkn dd. Ilic litr of llie mollier .ind child, tli.il aiil icip.il ion 
of it. and therefore early and iippni|iri;il( I n:il mcnl , arc of paraiiKinnI inip<ii laiici- in 
scicntilie niidwifcrv. 



200 



DYSTOCIA 



The causes may be tabulated according as they occur in the first or second stage, the 
first series delaying the dilatation of the cervix, the second the expulsion of the child. It is 
not out of place in this connection to add also the causes of difficulties in the separation and 
expulsion of the placenta, for delivery cannot be said to be complete until the placenta is 
expelled. 

Causes of Delay in Completion of the Three Stages of Labour. 



I.s7 Sluge. 

Weak uterine contractions 

Rifiidity of cervix: relative, 
spasmodic, cicatricial, new 
urowths 

Pendulous belly, causini; ante- 
version 

Early ruptiuc of membranes, 
line to malpresentations, 
morbid adhesions to the 
lower uteriiK" sef;nient, lui- 
<lll<' ri[:.hililv 

,M;[|pics( nl.ii lull, ill general 
Any(liiiij:i uliicli ]irevents the 

held entering the lower 

uterine segment 
Ilydramnios 

Delioienev (if liquor anniii 
Twins. 



3rd Stage. 
Weak uterine contractions 
Jlorbid adhesion of placenta 
Uterine spasm 
' Hour glass ' contraction 
Adhesion of membranes 



•2ii(l Stage. 
Weak uterine contractions 
Secondary uterine inertia 
Absence of accessory muscular 

effort 
Rigidity of vagina and ]ieri- 

neum 
Loaded rectum 
Distciiikd lila.lder— evstoeele 
Coiitiactcd prlvis 
Pelvic tumours: P^ibromyoma. 

ovarian tumours, growths of 

the pelvic bones, luematoma. 

varicose veins, vaginal 

growths 
.MaI])rcscntations ; Occipito- 

posterior, breech, face, brow, 

transverse 
.\ny abnormal enlargement of 

tiie child : Hydrocephalus, 

meningocele, ascites, tu- 
mours, double monsters, 

very large child 
Excessive ossification of the 

head 
Short cord : absolute, relative 
Locked twins 

From the above it will be seen that the causes of delay are very numerous and im- 
portant ; and the successful delivery of the child under many of these conditions depends 
\ery much on their anticipation, rather than their recognition when delivery is alreadx' 
dangerously obstructed. Conse((uently, accurate diagnosis at the beginning of labour 
will often save much trouble to the practitioner, and danger to the mother and child. 
Indeed, some of the dangers of obstructed labour can only be avoided satisfactorily by 
carcful examination of the patient during pregnancy, say at the thirtieth week. This 
applies specially to the recognition of contracted pelves, of pelvic tumours, and sometimes 
of malpresentations, and constitutes an important reason why every ])atient should be 
urged to undergo an examination during the later weeks of pregnancy. 

The routine method of examination of the juegnant woman, whether in labour or not, 
is the same : and the deductions to be mafic from it are identical. The examination is made 
as follows : lirst, by abdominal ])alpation : secondly, by vaginal examination. 

Abdominal Palpation. — First feel for the foetal head in the pelvis by the ' pelvic 
grip," or Pawliks grip. In a primipara the head shoidd be well down in the pelvis ; not 
necessarily so in a multiiiara. Failing to find the head in the )jelvis, palpate for it at the 
fundus ; failing to find it hci-e, it will be found in one or the other lateral situations. If the 
head is in the pelvis, and fixed, there can be no pelvic contraction of importance, and 
tumours of the uterus or ovaries beloic the brim are quite unlikely. If, however the head 
is above the brim and movable in a primipara, pelvic contraction must be suspected, whilst 
a tumour iireventing entrance into the pelvis is a possibility. Pelvic contraction may be 
\erihed by ])elvimetry, for which see below. Abnormal presentations are recognized by 
abdominal palpation ; breech and transverse by the actual position of the head ; occipito- 
posterior by the presence of the • small parts,' arms and legs, in front, and tlie absence 
of the back of the foetus ; a face cannot be diagnosed absolutely excejit in mcnto-postcrior 
cases, when the groove between the extended occiput and back will be felt in front whilst 
tlie head remains above the brim. Hydramnius may be recognized if there be fluctuation, 
and the ftt'tal parts can only be felt by dee]) dipping through the fluid. Trcins may possibly 



DYSTOCIA 201 

he recoiiiiizcd Ijy feclini; two licads. and hearing two foptal hearls heating with (Uffeicnt 
rhythms. 

Vaginal Examination. — It is iniixntaiit to reineTnl)ei' that very httle eaii Ik- iiukU' out 
with one or two lingers. As a rule, all that can he noted is the roiiditinu of the aiiial. whether 
narrow or rigid, with a powerfully acting levator ani nuiscle. and the coiuUtiuii o/' tlic un ; note 
especially its consistence, and the integrity of the membranes. It may not even be possible 
to recognize the presentation if this has not been made out by abdominal palpation. If con- 
tracted pelvis is suspected, the important diameter, namely, the diagonal conjugate, should 
be nieasm-ed with the fingers, and the true conjugate estimated by subtracting half an inch 
from tills measurement. The only accurate instrument for taking this measurement is 
Shiil.srh's pchiinelcr : but its use requires considerable experience, and. in general, the simpler 
method with the fingers is sufficiently accurate for most ])ur])Oses. External measurements 
may l)c made to supplement the important internal one ; but they are not of the same 
Ijractical importance. AVhen a difficulty arises in labom-, accurate diagnosis is indispensable, 
and the whole hand should be inserted into the vagina under ansesthesia. Tlie presenting 
part may then be grasped, and its absolute character determined. In this way oceipito- 
posterior presentations (the commonest cause of dilficult labour) can be diagnosed with 
certainty, and rectified. Hydrocephalus may be recognized by this manoeuvre ; the hand 
may be pushed on above the head without danger in most cases, and the neck felt for coils 
of cord, the body of the child palpated for the presence of tumours or enlargement by 
ascites. Tumours obstructing delivery are best felt from the vagina : they are usually 
wedged l)etween the presenting part and the sacral promontory, part below and part above 
this ])roininence. If fluctuating and soft they are usually ovarian cy.sts ; if hard and 
unyielding they may be fibromyomata of the uterus ; but these also are apt to soften during 
pregnancy, and to feel like fluid tumours. Tmnours of the pelvic bones are usually bony, or 
cartilaginous : growtfis of the cervix may be fibroid. I)ut more commonly arc friable carcin- 
oniata. bleeding freely on examination. 

Little more than the method of examination can l)e indicated in a short ailicle on the 
diagnosis of a case ol' dillicult labour : but too much stress cannot be laid on the \ahic of 
abdominal examination and palpation as the most important means of gaining inlormalion 
in any labour. 

Delay in the Delivery of the Placenta, though not strictly a part of dilficult labour, 
presents dilliciiltics in the completion of (leli\ery. and must not be overlooked. The 
placenta may he sim|)ly retained in utero : may be adherent to the uterus, totally or 
[)artiall\- : or may be retained in the vagina. In the first ease, if there is no luvmorrhagc 
the placenta is likely to lie in the lower uterine segment and vagina, and is not expelled 
owing to weakness of the accessory muscles. If partially adlicrcnl. bleeding is (•( rtaiii to 
occur, whilst total adhesion does not permit of any bleeiling. In any e;isc of this kind if, 
after a snITieienI time has elapsed, the placenta caimot be expressed, the hand nnisl be 
introduced into the uterus in order to diagnose the condition. It nnist not be forgotten 
that the plaeeiitii may be retained above a s|)asmodie stricture of some part of the uterus, 
the so-called lioiir-glass (•oiilraclioii. Ila-morrliage always accompanies lliis coiKlil ion il the 
placenta ik partl\- separated. 

I'MnaJly. the siini/ildiiis of cilKlilslidii cin\\ii]t[r\\\ upon olisl ruelecl laliour may he men- 
tioned. 'I'Ik' lirst are rise of temperature and increase in rrei|n(ii<v ot the pnlse-rale. These 
allord very important indications of obstructed labour, and assist us to distinguish this 
from simple delay from weak uterine contractions, in which the pulse and temperature 
remain normal. The later syni|)toms of ol)struclion. il nol iiiicMil. are Idc.il and general. 
].,ocally. the vaginal secretions fail, the parts become hoi, ilry, and swollen. The uterus con- 
tracts powerfully, and may go into a tetiuuc condition, usually known as Ionic contraction, in 
which case the nieriis is hard. ncv<-r relaxing, and is lender to. the touch. The exact op|)osile 
occurs in uterine inertia, when the uterus remains llaccid, along with a normal pulse and 
temperature. Later still, vomiting may occur, signs of septic iid'ection may appear, and 
ruptm-e of the uterus may take place owing to the dangerous thinning of the lower segmeni 
when liinic coiil rael i(]ri siipei \ iiies. This series of symptoms shoidd never occur in properly 
eoiiducldl midwilriy ; llicif |inssililc uceurrence should always be aidicipated by correct 
diai;ii(isis e:iily in laliour. rdlliiwcd li\ immediate a|i|iropri;d e Irealminl. '/'. (i. SIcitiik. 



202 EARACHE 

EAR, DISCHARGE FROM.— (See Otorrhcea. p. 421.) 

EARACHE is tlie term usually applied to the pain experienced in acute inflammation 
of tlie niidille ear. It is most acute when suppuration ensues. There are. however, a 
number of other conditions -many of them of great importance — which also give rise to 
otalgia or to pain roughly localized by the patient to the ear. 

In acute otitis media the pain is usually dull, continuous, and throbbing, with sharp 
exacerbations in which the pain shoots to the occiput, to the top of the head, or forwards 
to the temporal region. It is usually worse at night — indeed it may disappear in the day — 
and it is increased by pressure over the tragus and on ojiening the mouth. Xot infrequently 
there is some tenderness over the mastoid process. There is always some impairment of 
hearing. In adults there will probably be a slight rise of temperature ; in children the 
temperature may rise to 103° F., or more, the pain is often very acute, and constitutional 
symptoms may be very marked, with convulsions, vomiting, and delirium. Such cases 
may be mistaken for meningitis, especially in children too young to talk : but in these little 
patients attention may be directed to the trouble by the extreme tenderness of the affected 
ear. the least manipulation of which may cause the child to scream. In young children 
the presence of cerebral symptoms with pyrexia should always lead to a careful examin- 
ation of the ears. The presence of optic neuritis favours a diagnosis of extension of the 
inflammation to the Interior of the cranial ca\'ity, but this is not a universal rule, for cases 
are recorded in which otitis media by itself has caused optic neuritis. Attacks of earache 
in childhood are frequently caused by adenoids, and indeed, acute otitis media is prac- 
tically always caused by an extension of inflammation from the nasopharynx along the 
Eustachian tubes. When suppuration occurs, the membrane becomes perforated, pus 
escapes, and the pain usually ceases. When it persists, the perforation is probably too small 
to allow of satisfactory drainage of the pus. Examination of the tympanic membrane by 
means of a speculum will show redness, loss of lustre, and probably bulging of the mem- 
brane, with blurring of the handle of the malleus. 

Chronic middle-ear suppuration is usually painless. When necrosis occurs pain is often 
present and may be very acute, but this is by no means invariable, and some cases of 
extensive caries are i-emarkably free from pain. 

Pain and tenderness over the mastoid process are also present in acute mastoid abscess 
and periostitis. 

Pain in the ear may also be caused by the following lesions of the external auditory 
meatus, which may be diagnosed on examination through a speculum : — 

A foreign body, especially if an insect finds its way into the meatus. 

Furuncles ; intense pain, often throbbing in nature, is followed by a discharge of pus, 
after which the pain diminishes : the meatus is so tender that it may be impossible for the 
patient tf) endure the ])resence of the speculum. 

Ccruiiicn is usually painless, though sometimes a dull pain may be present. 

Kczetnn of the meatus may be the cause of a burning or smarting pain. 

Sometimes a careful examination of the ear will fail to reveal any lesion. Under 
these circumstances the possibility of one of the following causes of referred pain must 
be considered : — 

A carious molar tooth, a \ery common cause of pain referred to the car. 

Epithelioma of the tongue or ulceration of the pharynx or laryihr ; pain in the ear may 
be a very troublesome symptom of any of these. 

Acute or subacute tonsillitis often causes acute pain in the ear without any inflammatory 
lesion of the middle ear. Less frequently, suppuration in the accessory sinuses of the nose 
has a similar result. 

Otalgia may sometimes be neuralgic, and it is then usually associated with trigeminal 
tieurcdgia. It may also occur in nervous anaemic patients, and sometimes must be regarded 
as a neurosis. It must also be remembered that the glenoid lobe of the parotid gland extends 
into the non-articular portion of the glenoid fossa, and thus parotitis may cause pain referred 
to the ear. Similarly otalgia may occur with osteo-arthritis or inflct'inmatory trouble in tlic 
temporo-mandibular joint. 

Certain diseases of the am-icle may cause pain more or less severe in character. Peri- 
chondritis is by no means uncommon. It may be traumatic or spontaneous, and in the 



ENLARGEMENT OF THE FOREHEAD -lOo 

latter syphilis may be the cause. Herpes, acute eczema, erysipelas, Ra^^laud"s disease, 
and chilblains are all accompanied by jjain and may affect the auricle. Sebaceous cysts 
and dermoids also occur here, and when inflamed will cause more or less severe pain. A 
condition known as " Telephone ear ' has been described in persons who constantly use the 
tele])honc. More or less severe pain is present, and this may be accompanied t)y tinnitus 
and associated with the presence of boils. 

Lastly, it must be remembered that there is a lym])luitic <rhind situated over the mastoid 
process which drains lymph from the side of the scalp : when inflamed, this gland may be 
the cause of pain and tenderness, which may lead to a susjjicion of suppuration in the 
mastoid process. PJiilip Turner. 

ECCHYMOSIS— (See PuRPL-R.v. p. .552.) 

ECTHYMA.— (See Sc.\bs, p, 599.) 

EFFUSION, PLEURAL.— (See Chest. Bloody Ei-i tsuin ix. ]>. 102 : ( hkst. Skrols 
Effcsion in. ]). 104: and C'ukst, Pu.s in. p. 108.) 

EGG-SHELL CRACKLING.— (See Crackling. Egg-.shell, p. 150.) 

ELECTRICAL REACTIONS.— (See Re.vction of Degeneration, p. 582.) 

EMACIATION. (See .Marasmus, p. 384 : and Weu;ht. Loss of, p. 768.) 

EMPHYSEMA, SURGICAL. — Surgical or subcutaneous emphysema is due to disten- 
tion ol llic miIk utaiiidus areolar tissues with air or gas. The diagnosis of the condition and 
its cause is not as a rule diflicult. Its commonest starting-place is in connection with the 
thorax, particularly when there has been injiiri/ to the linig tissue by a broken rib, a stab 
with a knife, a bullet wound, the rupture of alveoli due to excessive coughing, as in whooping- 
cough and bronchitis, or during great strain, as in dillicull labour ; or by operative injury 
lo the lung, as in ex])loraton.' needling of the chest. Tlie gas spreads rapidly, and may 
extend over the greater part of the trunk in a short time, disappearing again in the course 
i>l a few <lays. It may do so similarly after the operation of trachvoiomij. 

'I'he face may sometimes be almost suddenly involved unilaterally by the escape of air 
into the Mibcutaneous tissues from the upper pail of the nose, after violent sneezing or 
energetic hl(t;.K:in<i of the nose. 

Rarer causes for the escape of actual air into the subcutaneous tissues are nhrrnlive or 
iniiimfilie lesions of the (I'soplingiis. stomaeli. duodenum, ecvcnni. hhidder. or rectum. \\v 
escaping in the areolar tissues arouiul any of these p:Mts may sometimes extend and Ikcomic 
palpable as crepitus under tlie skin. 

Quite another ty]je is that in which the gases in the tissues are not air. but the results of 
injection lii/ giis-jjroducing Ixictcriii. Fortunately <'ascs of this kind are now rare ; they were 
less uncommon in the days of lu/spilul giingrenc and putrefaction. Tlic J{(uillus coli com- 
munis, however, not infre(|ueiitly liberates gas in an abscess lo which it may give rise — for 
instance in the region of the vermiform appendix — and sometimes subcutaneous emphysema 
results, .\nother gas-producinu organism that attacks maiL though less often as a primary 
aftcetion than intcrcurrcntly during some oilier malady, is the Hiicillus (icrooencs cu/isulalus ; 
this. howe\(r. more often produces gas-coiitaiuing loeuli in the liver ami oilur internal 
organs than in the tissues beneath the skin. Ilcrhcrl Frcnrli. 

EMPYEMA. (See Cmi-.st. I'i s in. p. lo;j.) 

ENLARGEMENT OF A BONE. (Sec Swi-.i.linc; on \ Moni;. p. on?.) 

ENLARGEMENT OF THE FOREHEAD. Mans indis i.hials hIh, j.avr passd 
iiiiildli- -.iiic mails ni<)i<- so llian Icinalis Icnil lip dcMJiip .in iiicrciisiiig pi<iiiiiiieiiee of 
I In 1 1 |i:ir I dI II ic- ruirlicMd which corresponds « jlli II ic milcr ciisiii^ cif II ic frontal air sinuses ; 
«illi llir Ksiili ||i:il I heir eyebrows seem to oxcrliaiii; llic i yes iiioic and more, and the 
eoiiiiteiiaiicc looks dilferent to what it did ten or lifleen ncmis Ix Ion'. This is due to slow 
enlaigeinent of the air cells of the frontal sinuses, and it is not pathological. This normal 
enlargement of the forehead has to be distinguished froin two diseases which, though rare, 



204 ENLARGEMENT OF THE FOREHEAD 

arc generally recognizable with ease if the patient is watched over a jjeriod of months or 
years, namely, leontiasis ossea and acromegaly. 

The commonest symptom that a patient suffering from leontiasis ossea complains of is 
fluit in former years he always took a certain size of hat, and was able to order hats without 
having to go and try them on ; of recent years, howe^■er. he has found that he has had to 
get progressively increasing sizes, so that whereas formerly a number 7 may have fitted him, 
he may now require even so large a size as a number 8 ; in a few exceptional cases special 
hats have had to be made for the patient because the enlargement of the head, especially 
of the forehead, has become tremendous, whilst at the same time it may very likely not be 
quite symmetrical. The general health remains good, and if the patient docs not mind his 
])ersonal appearance and the size of his hats, he lives for years without suHcriug any other 
inconvenience. On the other hand, the bony changes may not be confined to the skull, 
but may affect the bones of the limbs as well, especially the tibise ; there is probably a 
relationship between leontiasis ossea and osteitis deformans or Paget's disease of the bones 
(see p. 135). If the cranium is examined after death, it is found that there is no longer any 
distinction between the hard ivory bone upon the sin face of the cancellous bone in the centre ; 
both have assumed an intermediate character, so that the whole bone is more or less of the 
same texture, very thick and heavy, and in a condition which used to bespoken of as osteo- 
porosis. In some cases the change is syphilitic. 

In acromegaly it ha])pens very rarely that the frontal bone is affected alone : much more 
often the affection of the forehead is much slighter than the increase in size of the lower 
jaw and of the phalanges of the hands and feet (p. 237). If, however, the changes were 
more marked in the frontal bone or in the bones of the skidl generally than in those else- 
where, it is probable that a case of acromegaly woidd be diagnosed as one of leontiasis 
ossea, and one does not really know what essential difference there is between these two. 
Whereas, however, in acromegaly the bigness of the lower jaw makes the characteristic 
fiuies, in leontiasis ossea the )3rominence of the forehead gives the face that leonine character 
from which the name of the disease is taken. 

No other maladies in adidts are likely to cause uniform increase in the size of the fore- 
liead, but occasionally one meets with tumoiu's of the frontal bone which cause a symmetrical 
enlargement of the forehead, the most important of these being the ivory exostosis — a non- 
malignant tumour which may arise from any of the flat bones of the skull ; it grows very 
slowly but enlarges progressively, and in so doing is apt to displace anything which comes 
in its way, and in the course of many years great deformity of the eye or nose may thus 
result. The slowness of the growth, and its very hard character gencrall\'. ])oint to the 
diagnosis at once, and an .r-ray examination may help to confirm it. 

Other asymmetrical enlargements of the forehead may result from syphilitic nodes 
caused by gummatous periostitis terminating in bony organization ; sareoTna of the peri- 
osteum, a very rare primary growth in this region, but when met with suggested by the 
relative softness of the mass and its rapid increase in size ; secondary iiiatignaiit disease. 
likely to be mistaken for jirimary sarcoma if no jjrimary growth elsewhere is known, but 
readily diagnosed correctly if the existence, now or formerly, of a carcinoma of the breast, 
thyroid gland, or other part is known. 

.\ny other tumours in connection with the frontal bone are exceedingly rare. The 
\ ery extensive disease of the frontal, as of any other cranial bone, which used to be met 
^\ itli in syphilitic subjects, is now practically imknown on account of the greater adequacy 
of the treatment of syphilis in its earlier stages. 

Leproiy maj- be mentioned as a cause of enlargement of the forehead (,Fig. 173, p. 404), 
for in the nodular form any part may be affected ; but it must be very rare for leprosy to 
allect the forehead region only, and the diagnosis will be suggested by the lesions elsewhere 
and l)y the history of the case. 

The above remarks apjjly to enlargement of the forehead in adults ; in children quite 
<lilferint causes will suggest themselves, the three most important being : (1) Ilydro- 
cephaUis. (2) Rickets. (3) Congenital syphilis. 

It happens not infrequently that a child's forehead enlarges very considerably, and 
bulges with much convexity to such an extent as to make both the parents and the physician 
fear hydrocephalus when the child is suffering from nothing more serious than rickets. 
The diagnosis may be quite difficult if there are not at the same time the other familiar 



EXLARGEMENT OF THE FOREHEAD 205 

signs of rickets mentioned on page 167 : and there are not a few instances in which it is 
only wlien the ease has been watelied for months or years that one can be sure that there 
is not hydroeepliahis. The same applies to the swelling of the frontal bone that may result 
from congenital syphilis. In the case of both rickets and congenital syphilis, one will 
examine the whole of the head carefully, to try and make upone"s mind whether the enlarge- 
ment, which usually allects not only the forehead but also other parts of the skull, is a more 
or less uniform stretching such as hydrocc])halus gives rise to, or whether tliere are not 
some parts which are enlarged and other jiarts which are more or less normal. Both 
congenital syphilis and rickets are apt to produce diffuse round prominences of the parietal 
regions as well as of the frontal regions, so that there are four main bulges with an antero- 
posterior and a transverse groove between them, constituting the hot-cross-bun-shai)ed 
type of head : but the difficulty of excluding hydrocephalus is made greater still when, as 
sometimes hap))ens. there is such tliinning of the bones in the occijiital region from cranio- 
tabes that the bones can be dented inwards like stiff parchment : such cranio-tabes may 
result either from rickets or from congenital syphilis. One woidd then pay special atten- 
tion to the regions of the sutures ; if these arc obviously stretched asunder the case is almost 
certainly hydrocejjhahis. and not rickets or congenital sy])hilis. One would also be able to 
draw some conclusion perhaps from the a])i)caranccs of tlie eyes, for the eyeballs will be 
in normal position when the cause of the forehead enlargement is rickets or congenital 
sy|)hilis, whilst with hydrocephalus the eyes will give the impression of being displaced ; 
sometimes they look very much deeper set than normal ; in other cases they look as though 
they are depressed as the result of the downward ])ressure exerted by the excess of fluid 
upon the roofs of the orbits. If the enlargement and prominence of the forehead dates 
from birth or soon afterwards, this will be an argument in favour of hydrocephalus ; if the 
change develops later in the infant's or child's life, there will almost certainly be a history 
of a se\ere attack associated with symi)toms of increased intracranial pressure, for 
])robably the commonest cause of acquired hydrocephalus is a preceding attack of meningo- 
coccal meningitis, from which the child has reco\ered. The history, therefore, may help 
in deciding the diagnosis. The optic discs should also be examined, for in a certain number 
of cases of aeipiired hydrocephalus there is optic atro|)hy (PIfitc A'A'. /•'/«• "• P- US), and 
this is practically never met with as the result of rickets and \ery seldom as the result of 
congenital syjihilis. It is of course only when the degree of hydrocephalus is medium that 
it is dillicult to distinguish it from the forehead enlargements due to rickets or congenital 
syphilis. .Major degrees of hydrocephalus cause such extreme enlargement of the whole 
head, conpied with such thiiuiing of the bones and stretching of the sutures that the dia- 
gnosis is almost umnistakablc. 

Although either sim|)le or malignant tumours may affect the frontal bones, even in an 
inl'ani or cliild, they are very rare. They should be diagnosed in the same way as similar 
tumours in adults. Chloroiiia may (jerhaps be mentioned specially, rare though it is. 'I'lic 
tumours in such a ease are never single, but as they may develop ujjon bones, they some- 
times attract notice first in coimeetion with the cranial bones, and tluis perhaps a local 
enlargement of the forehead may be the first symptom in the case. There isa tendene.y for 
the glands geneiaily to become enlarged and siimctimes the spleen also, and in some respects 
the iiiahiiiy sininhiUs lyrnplialic leuk;einiii. \<'ci|ilnsm of some kind will he an early 
siis|ii(jori. and llic naluir iif llic gr.iulli is indieatiil by llie gnciiisli ciilnur of llie tinnour 
ulirn it lias been excised. Tlic a<'lual diaiiuosis. iiowcMr. is made inoic ollcri post mortem 
lliaii (luring life. 

The eomnionest local swelling of the forehead in a child is a h(riiiiiliiiii<i resulting from 
injury, and as the blood clot is often (juite deep-seated there is sometimes no discoloration 
ol the skin, and some more serious tumour may lie thought of until the disappearance of 
the mass in the eciiiise of a week or two proxcs its simple cliaraeter. Such a lucmalom-i 
altera day or two sollens in ilsccniial part in a remarkable way. leaving very hard 
raised edges, and on palpation it feels almost as if there were a hanl bony ring with 
an absence of any bone at all in the centre ; the lirst time such a softening Inenudoma 
of the foreliead is fell, one can hardly believe that it is only a ha-niatonia and not an 
actual hole in the bone covered ni<i(ly by scalp an<l skin. The feeling, however, on 
l)alpation is so characteristic that once felt llie condition is rea<lily recognizable in any 
subseiinent case. lUrbert I'rciiili. 



206 ENLARGEMENT OF THE HEART 

ENLARGEMENT OF THE GALL-BLADDER. (S« G ali Hi auui.u Enlaugement, 

p. -'.-,12.) 

ENLARGEMENT OF THE HEART may be due to hypertrophy of the walls of any 
of its cavities, but especially of the ventricles ; to dilatation of the cavities ; or to these two 
conditions combined. 

The most important physical signs of enlargement of the heart are : (1) Displacement 
of the cardiac impulse: (2) .An increased area of cardiac dullness. .After puberty the normal 
cardiac imiiulse is usually situated in the fifth left intercostal space, about three-quarters 
of an inch internal to the left nipple line. Before puberty it is normally in the fourtli left 
space in the nipple line. Wiien the heart is enlarged, the impulse is displaced outwards and 
also downwards. Particular care must be taken to determine the exact position, as from 
this observation a good idea of the particular part of the heart which has enlarged may be 
obtained. When the left ventricle is much hypertrophied, the cardiac impulse is displaced 
more in a downward direction than outward, e.g., it may be found in the sixth or even the 
seventh left intercostal space in the nipjjle line or outside it. When the enlargement is due 
to hypertrophy of the right ventricle, the cardiac impulse is displaced more in an outward 
direction than downward, and frequently' there is also considerable pulsation in the 
epigastrium. 

Where the cardiac impulse is thus displaced, before cardiac enlargement is diagnosed 
the possibility of its mechanical displacement by fluid or air in the right pleural cavity 
pushing it, or a retracted left limg pulling it, over to the left, must be excluded by careful 
physical examination of the front and the back of the chest. In the case of pleuritic effusion 
the dullness on the right side of the chest, and the absent or deficient vesicidar murmur 
would point to fluid : in the case of retraction of the left lung the left side of the chest would 
be smaller, there woidd be deficient movement, didlness and deficient voice soimd and 
vesicular murmur, or possibly broneliial breathing, consonating rales, and pectorilociuy over 
the left lower lobe. 

The chnracler of the impulse must be noted carefully, for, when forcible and heaving, 
it denotes hypertrophy ; when feeble and dittused, dilatation. 

The cardiac impidse is invisible and impalpable in some cases of enlargement of the 
heart, on account of emphysema of the lungs. In these circumstances even the .r-rays may 
be required before one can be sure of the diagnosis of cardiac enlargement. 

Careful mapping out of the area of cardiac dullness may afford valuable information 
as to the j)art of the heart involved in the enlargement. If the area of deep dullness is 
increased downwards and outwards, an increase in the size of the left ventricle is indicated ; 
if upwards and to the right, hypertrophy of the right ventricle ; if in all directions, enlarge- 
ment of both ventricles. 

Enlargement of the heart in children may produce definite local bidging of the chest 
wall in the cardiac area. 

Having determined the position and character of the impulse, ma]3ped out carefidly 
the area of cardiac dullness, and thus arrived at the conclusion that the heart is increased 
in size, the next step is to determine not only what particular part is enlarged, but also the 
actual cause of the enlargement. 

ENLARGEMENT OF THE LEFT VENTRICLE. 

The left ventricle may become enlarged in ; — 

1. Aortic Disease: — Stenosis and regurgitation; regurgitation; stenosis; aneurysm 
of the first ])art of the aorta involving the aortic ring. 

2. Mitral Regurgitation : — Disease of the mitral valve ; dilatation of the kit ventricle 
involving the mitral ring. 

:5. Arteriosclerosis and Granular Kidney. 
1. Alcoholism. 

5. Long-continued Over-exertion: - ,\fhktes ; workers at laborious occupations, 
e.g., stokers, firemen, funiaeemen, blacksmiths. 

6. Exopbthalmic Goitre. 

7. Congenital Heart Disease. 



ENLARGEMENT OF THE HEART 207 

1. Aortic Disease. 

Aortic disease may cause very great enlargement of the heart — cor boviniim or bovine 
heart. In the Guy's Hospital Museum there is a heart of this kind whicli weighs 53 ounces, 
the normal weight being about 10 ounces. 

Stenosis and regurgitation is the commonest form of aortic disease, tlien regurgitation, 
and pure stenosis is the rarest. 

Aortic Stenosis and Regurgitation. — Tlie cardiac impulse is displaced downwards 
and outwards, and the cardiac dullness much increased towards the left. 

It may be in the hfth. sixth, seventh, or even eighth space in or outside the left niniile 
line, and may be as far out as the anterior axillary line. The further the impulse is down 
the larger the left ventricle, and the further it is out tlie more the dilatation. AVhen the 
impulse is forcible, heaving, and limited, it indicates that hypertrophy predominates ; when, 
on the other hand, the impulse is diffused and feeble, dilatation preponderates. Young 
people may present well-marked bulging in the jjrecordial area. 

A systolic thrill may be felt <>\er the base of the heart, especially over the second right 
intercostal space clo.se to the right border of the sternum. More rarely a diastolic thrill 
may be felt also or independently, either to tlic right or to the left of the upper part of the 
sternum. 

On auscultation, a systolic and early diastolic nuirmur are heard over the base of the 
heart. The former usually replaces the first sound, is loudest in the second right intercostal 
space close to the sternum, and is transmitted upwards towards the clavicle and into the 
carotids. It varies in character, being in some cases soft and faint, and in others harsli, 
rough, and loud. The diastolic might be described as post-systolic, for it replaces the 
second sound : it is generally soft and blowing, though in rare instances it is harsh or e\'en 
musical. It may be heard over the upper part of the sternum and on both sides of it. When 
the aortic incompetence is due to fibrosis resulting from endocarditis following acute 
rluumatisni or chorea, it is usually best heard to the left of the sternum, loudest in the third 
intercostal space dose to the sternum. When the incompetence is due to syphilitic atheroma 
or to aneurysm of the first part of the aorta, the bruit is generally loudest and best heard 
in the second space to the right of the sternum. The early diastolic bruit which denotes 
aortic regurgitation may also be heard at the cardiac impulse, and in some cases may even 
be traced outwards into the left axilla. It cannot be mistaken for a mitral stenotic bruit, 
because there is no inler\al between the second sound and it. If there is complete com- 
pensation, the first sound may be loud and clear at the u))ex, but if dilatation of the left 
ventricle has occurred, there may be a loud blowing systolic murnnu- re|)laeing the first 
sound and traceable outwards into the left axilla. Another bruit, which is rumbling In 
character and prc-systolie in time, may be heard at the cardiac im])ulse when the ventricle 
is dilated, the s<.-<allcd Flhil'.s bruit (/•'('«. 4.0, p. 95). 

I'iitieiUs arc usually anauiic, and the carotid, brachial, and (itlur superficial arteries 
are seen |)ulsatiug forcibly. .\ feeling of faintness on rising fioui the supine to the creel 
posture, di/./incss. headache, a sensation of throbbing in the extremities, palpitation, 
dyspiura, und precordial pain on exertion arc early manifestations of this disease. .Vs 
compensation fails, the dys])n(ra and palpitation increase, (cdema of the legs su|)crvcnes. 
pain becomes worse, and is felt not only over the region of the heart, but tends to radiate 
info the left shoulder an<l arm. and it may be followed by attacks of true angiiui pectoris. 

The ciiridiis splasliirig or ' waler-liammer " pulse is palhogridinonie : it is appreciated 
best if the radial pulse is fell whcti the arm is raised, the pulse-wa\-e striking the finger with 
a .sudden sharfi jerk, and then as suddenly collapsing. \Vheu eomi)ensation fails, the pulse- 
rate may become rapid and the beats irregular and intermittent, as in mitral disease, but 
earlier in the disease the rale and rhythm are normal. 

('fi/>illiiii/ piitsdtiiiii. which may be detected in the lips, finger-nail--, and skin, is a \ ( i y 
characteristic sign. It can be demonstrated by drawing a linger nail two iir three liuics 
across the skin of the forehead <ir abdomen, so as to produce a line of hypera-mia. wliieh. 
if watclud carefully, will be seen to blush and pale alternately, each blush being synchronous 
with the pulse. 

Aortic Regurgitation. The symptoms arc praeli(all\ iiie same as in aortic stenosis 
and rcgiugitalioii. but Ihirc is no svslolic thrill ami no well-marked s\sl()!ie l)ii]il in the 



208 



ENLARGPLMENT OK THE HEART 



aortic area. The pulse is of the typical water-hammer type. The presence of a soft systolic 
l)riiit in the second right intercostal space close to the sternum does not indicate aortic 
stent>sis unless there be at the same time a thrill there. 

Aortic Stenosis is the rarest form of aortic disease. In addition to the absence of a 
diastolic Ijruit at the base, there is a pulse very different from that of the water-hammer 
ty|)e. If there is full compensation the pulse is slow, frequently below 60, and it may be 
only 40. or less, to the minute. It is usually regidar, long sustained, and of good tension. 
A sphygmographic tracing shows a slow rise, often with an anacrotic break in the upcur\c, 
a broad summit, and a gradual decline. The mere presence of a systolic murnuu- in the 
aortic area, even if its point of maximum intensity be in this region, is not sufficient evidence 
on which to base a diagnosis of aortic stenosis. A little roughening of a segment of the 
aortic valves, slight sclerosis of a valve, atheroma or dilatation of the first part of the aorta, 
and even anjemia, may give rise to a well-marked systolic bruit in this region. Before 
diagnosing aortic stenosis of clinical degree, one should have a big heart, a harsh systolic 
bruit in the aortic area, and a corresponding well-marked systolic thrill. 

Aneurysm of the First Part of the Aorta is another important cause of hypertrophy 
(if the kit ventricle il the dilatation of tlie aorta involves the aortic ring, increases 

its circumference, and thus renders 
the aortic valves incompetent, 
though the cusps may be indi- 
vidually healthy. In addition to 
the characteristic pidse and the 
usual signs and syniptoms of 
aortic regurgitation, there may be 
several indications which point to 
an aneurysm of the first part of 
the aorta as the cause of the aortic 
incompetence : — 

There may be a distinct bulg- 
ing of the thoracic wall involving 
the first and second interchondral 
spaces close to the right border of 
tlie sternum. 

There may be well-marked 
pulsation in the second right inter- 
chondral space and also in the ad- 
jacent spaces, according to the size 
of the aneinysm, close to the ster- 
nimi ; when not obvious to the 
hand this may sometimes be de- 
tected by the ear laid flat on the 
chest. 

In addition to an increase of 
the cardiac dullness downwards and 
to the left, there will be dullness in the second right space close to the sternum. 
There may also be some signs of intrathoracic pressure : — 
The right carotid pulse may be weaker than the left. 

The face and neck may be deeply cyanosed if the aneurysm has extended outwards 
and has stenosed the superior vena cava, though this is a rare occurrence in this disease 
{Fig. 69, p. 158). There may be a loud systolo-diastolic bruit audible in the second right 
sjjace over the superior vena cava, with maxinunn intensity an inch or more to the right 
of the sternum. The superficial veins over the upper part of the riglit side of the chest in 
front may be varicose {Fig. 93), and the direction of the blood-current in them may be from 
above downwards, instead of from below upwards. 

The right bronchus may be stenosed if the aneurysm ])rojects posteriorly, and this leads 
to impairment of percussion note and deficiency in the vesicular murmur over the upper 
lobe of the right lung. The ,r-rays might be used to determine the diagnosis {Fig. 100), 
though the aortic diastolic bruit should serve to distinguish aneurysm from new growth. 




Fig. 09.— Obstruction tn tlie siilierior tcim cava hy an a 
mysm ; collateral circulation tllrougii the distended superficial ^ 



exlar(;e.mext of the heart 



A diannosis of aortic disease 
determined. It may be due to :- 
1 . Lesions of the J^alves : — 



incomplete until tlie aetvial cause of the lesion has tieen 



Acute endocarditis 

Fibrosis after former endocarditis 

Infective endocarditis 



Sclerosis due to : Strain (persistent), Sypliilis, 

Alcohol 
Rupture of a segment 
Congenital malformation. 

2. Dilnlalioii iij llic Aniiic liiiii; from Aneurysm of the first portion of the Aorta. 

Lesions of the Valves. 

Aeiite Endocarditis occurs most frequently as a complication of acute rheiunatism, 
chorea, or scarlet fever. The indications of acute inflammation of the aortic valves will be 
a systolic murnuir in the aortic area, and less commonly an early diastolic (post-systolic) 
murnuir, which first becomes audible in the third left space close to the left border of the 
stcrnimi. If the bruits arc already j)resent 
when the ])aticnt is first seen, it may be dillicult 
to <lccidc whether they are due to existiny 
acute inflammation or to fibrosis after former 
inflannnation. They may be noticed to arise 
whilst the patient is under treatment in bed 
for acute rheumatism, and then their acute 
nature will be obvious. In cases in which the 
bruits are <lue to acute aortic endocarditis and 
not to |)crmancnt fibrosis, the ])ulse will have 
little of the watcr-hannner type, the heart will 
not be nnich hyijcrtrophied, though it may he 
dilated from acute rheumatic toxa'inia, and the 
bruits will be found, as the days go by, either 
to diminish or increase in intensily. according 
as the inllanunation of the valves resolves or 
passes on into permanent fibrosis. 

Fibrosis from Previous Endocarditis. — 
When aortic disease is due to fibrosis from 
previous endocarditis, there will generally be a 
history of attacks of acute rheumatism, chorea, 
scarlet fever, or tonsillitis. The diastolic bruit 

which indicates the presence of aortic regurgi- tiieali. h.in, • i'. ,i'i .,1 i'lu nvi, ,,1 iii mi ■ 1 bi tnmsverse 

tatiou is heard best along the left border of the phr',,.',',! ' ' "ei' 'i ' " '^ i"i \.'°r*:sV '/!)'//■.' Ifirnf'c. 
steriuun, the point of maxinnun intensity being ./oni,,,,. 
in the lliinl left intercostal space close to the 

left border of the stermun. There will generally be evidence of organic mitral disease at 
the same time, and if mitral stenosis be associated with aortic disease, whether there is a 
history of acute rheumatism or not, the vjilvular lesions may be considered without doubt 
to be due to the cITccts of former cndocarditiN. The patients arc gcniiiUly cliildren or 
young adults, though a few survive into middle life. 

Jnfectiic Endocarditis. — In this form of endocarditis, in addition to the signs and 
symptoms of aortic disease, there may be others, described on p. ;i t. In some cases bac- 
teriological examination of the blood fleteets such organisms as the Strcjitococras jii/oficiics. 
.Stdjilii/lococciis pifo/ienes aureus. Micrococcus rlicunialictis. I'licuiiioinccus. or ollicrs. 

Sclerosis not due to former Endocarditis : 

Strain. -Persistcid strain is an imporlaid factnr in the production of aortic disease. 
Occupations ciUailing long and contitujcd manual labour, and exccssi\c in<lulgcncc in 
athletics, may thus lead to incompetence. The tendency- is not nearly so great, however, 
in lliosc who have not had sy|)hilis as in those who have : so that sclerosis from strain 
alimc nnist not be diagnosed uidcss there be neither a history nor evidence of rheumatism, 
chorea, syphilis, or alcoholism, 

Si/pliilis. — A history of syphilis, and any nianilcstal ions oi' this <liscasc in the form of 
piiimented scars on the legs. bo(l\. and lace, nici laliim ol llic tongue, patches o! lenkophikia, 

I) ' It 




•210 ENLAKdE.MENT OF THE HEART 

ulci'iatiim. ,sciuiint>, or perforation of the jnilate, necrosis of the nasal bones, etc., would 
point to this disease as the cause, and this conehision would be strcnathincd if there were no 
previous history of rheumatism, scarlet fever, or chorea. The AVasserniann reaction may 
be positive. The patients are nearly always males who have worked hard, and their first 
symptoms are often brought on by some undue muscular effort which strains the enlarged 
heart, or even bursts an atlieromatous patch in the diseased valve. Uncommon before forty, 
the lesion is met with often enough between forty and fifty ; in many cases the heart lias 
been passed as normal at forty, whilst at forty-five the aortic regurgitation is extreme. 
These patients often suffer from verj- severe attacks of angina pectoris, to which they are 
much more liable than are rheumatic aortic cases. 

Alcohol. — The constant use of alcohol raises arterial tension and may be followed by 
sclerosis. The general apjiearanee of the patient, and the signs described on p. 726, would 
suggest alcohol as the cause in the absence of any evidence of rheumatism or syphilis, but 
alcoholism without sypliilis leads to definite aortic disease less often than it does to a generally 
hy|)ertrophied heart, which sooner or later exhibits fibroid or fatty degeneration. 

Rupture of a Segment of the Aortic f'alve is a rare occurrence, usually brouglit about by 
some severe and sudden muscular exertion. The following is a good illustrative case of 
aortic regurgitation caused by rupture of a valve segment. A sailor, who had been examined 
just previously and passed as sound, was one day pulling on a rope, when suddenly the strain 
on it was unexpectedly and much increased. He made a tremendous effort to prevent the 
rope slipping through his hands, in doing so fainted, and was picked up in an unconscious 
condition : on coming round he was very dyspnoeic, and complained of pain in the pre- 
cordial region. When the doctor examined him again he foimd a well-marked musical 
early diastolic miu-mur in the third and fourtli left intercostal spaces close to the sternum, 
and came to the conclusion that as his heart soimds were normal before the accident, he 
must have rujjtured one of the segments of his aortic valve and thus caused the incompetence. 
Tiiere is always the proli;il)ility of sucli a valve having been jjreviously the site of syphilitic 
atheroma, without bruit, until the extra strain caused a weak spot to give way suddenly. 

Cougenital Malformations of the Aortic Talves are extremely rare, and tliey are to be 
diagnosed with great caution. 

Dilatation of the Aortic Ring from Aneurysm of the first portion of the Aorta is 
nearly always due to sy|)liilitit- atluronia of the aortic walls, and in such a case it will be 
probable tliat there is syi)hilitic disease of the aortic valves themselves also. The dilatation 
of the aorta (" fusiform aneurysm ') will be indicated by definite impairment of note in 
the second right intercostal space near the sternum ; and the .r-rays will confirm it. It will 
be next to impossible to assess with any degree of accuracy how much of the aortic regurgi- 
tation is due to the dilatation of the ring, and how much is due to the concomitant valve 
changes. 

2. .AIlTRM. Kegurgitatiox. 

As a residt of mitral regurgitation the left aiuiclc becomes dilated and hypertrophied, 
the left ventricle dilated and hy])crtniphied. and later from backward pressure the right 
ventricle and auricle may be affected similarly. The chief symptoms are dyspnoea on exer- 
tion, palpitation, congestion of tlie face and lips, cough, possibly hiemoptysis, oedema of 
the feet and legs, and later albuminuria, ascites and enlargement of tlie liver. In the early 
stages the pulse may be regular, full, and of low tension. When compensation begins to 
fail, tlie pulse becomes rapid, irregular, and intermittent. The cardiac impulse is displaced 
downwards and outwards. It may be in the fifth intercostal space in the left nipple line, 
or outside it, or in the sixth space outside the nipple line. It is usually diffused, and there 
may l)e epigastric pulsation. There may be marked bulging of the precordial area in 
children. A systolic thrill is rare, but it may be felt at the cardiac impidse. 

The cardiac dullness is increased outwards and downwards, but also upwards and to 
the right wlien the right side is involved. 

At the impulse there is a systolic nunniur. usually of a fjlowing character, wliich may 
cither follow or rej)lace the first sound. It is Ijest heard at the cardiac impidse, but it can 
generally be traced outwards into tlie left axilla, can sometimes be heard behind at the 
inferior angle of tlie left scapula, and can also be traced inwards towards the left border 
of the sternum. Tlie pulmonary second sound is accentuated or reduplicated in the second 
interspace close to the left border of the stermuii. 



ENLARGEMENT OF THE HEART -211 

When coiiiptiisatiou fails, in addition to the above there- may be : — 
A systohc nuniiiur. softer tlian and different in ehavaeter from that at the impulse, 
over the lower part of the stermmi and the fonrth aiifl fifth left interspaces, due to tricuspid 
regurgitation : (I'dema of the feet, legs, and lower part of the body ; abdominal distention 
from ascites : enlargement and ])ulsation of the liver ; signs of hydrothorax ; albiunimu'ia. 
A diagnosis of mitral regurgitation is incomplete by itself, for it may be due to different 
conditions. It is necessary to determine, if possible, the actual cause of the defect. 

Causes of Mitral RegiirgitatioN. 

1. Lesions of llic Milral f'alve : — 

.\cute cndocMfditis i Fihrosis the result iif former 

Infective endocarditis I ciulocarditis 

2. Dilatation, or Ilypertropliij anil Dilatation, of the Left Ventricle, without organic changes 
ill the Mitral Valve itself : — 

Secondarv to aortic disease 

Secondary to increased systemic blood-pressure : — 

Chronic Bright's disease | Arteriosclerosis. 

3. Diseases of the Myoeardiuiu and Pericardium : — 
Myocarditis Pcrieioditis 

Fatty degeneration Adherent jjcricardiuiu. 

Fibroid degeneration 

4. Acute Dilatation of the Heart fruni : — 

Over-exertion | .\cute febrile diseases | .\cute ne])lultis. 

Lesions of the Mitral Valve : — 

Acute Endocarditis. — Simple acute endocarditis is not a disease per se, but occiu's as 
a eom]>lication of some other disorder, especially acute rheumatism, chorea, and .scarlet 
fever. It sometimes complicates tonsillitis, which is in many instances a numifeslation 
of rheumatism occurring without any changes in the joints : and in children acute endo- 
carditis may be the only indication of an attack of rlicumatism. There are no characteristic 
.symptoms which point to acute endocarditis. If in the course of acute rheimiatism the 
I)atient complains of a little jjalpitation, precordial pain, and distress, and it is foimd 
that the licart action has increased in rapidity without any increase in the Joint affection, 
endocarditis should be suspected. The tempcratiu'e chart seldom indicates the complication. 
.Vt first the position of the cardiac impulse and the heart-sounds rcnuiin normal, bid if 
watched froML day to day. endocarditis having developed, the impulse will be found lo have 
nu)vcd outwards, the first sound becomes prolonged and roughened, then doubled, and in 
a lew days it is either followed or replaced by a, loeali/cd soft blowing systolic murmur. 

Fdirosis the result of Previous KniUiearditis. If aeulc endocarditis of the nutral valves 
docs not resolve, the vahe-llaps become sclerosed, and in the later stages even calcilied. 
In many cases the circumfercnee of the orifice is narrowed, so that the valve is not only 
ineompctcid but also slcnosed. A diagnosis of librosis after endocarditis as the cause of 
milral incompelencc may be made if there is a previous history of acute rheumatism or 
clinrea,. and independently of such a history if there is evidence of stciu)sis as well as regurgi- 
laliiin. If actual mitral stenosis can be diagnosed with certainly, if must be due lo librosis 
liiiin cn(|.)carditis. Ihougli there may of course be recent endocarditis as well. 

Infective Endocarditis of the mitral valve suggests itself if fhcrc is a milral broil, and 
if any of I he symptoms and signs meidioned on page ;! t are picsriil a I I lie same lime. 

Hypertrophy and Dilatation of the Left Ventricle. 

Seeiinihirii In Aortic Disease. ,\<)rfic disease leads lo hypertrophy of the left veufriclc. 
Ibllowcd after a lime by diialafion of that cavity and milral rcgurgilafion. Marked pulsa- 
linii of the superficial arteries, a splaslung pidsc. capillaiy pulsation, and llie systolic and 
early diastolic murmur at the base of flic heart, flic former best heard in Ihc second rigid 
space close to the sfernmn. and flic latter in llie lliird left space close lo Ihe left border ol 
the sferniim. would indicate the presence of aorlic disease. If flic palicnl has siilfcred from 
eilher rlieiimatisni or cliorea. Hie milral regiirgif al ion might be ilui' lo primary endocardilis 
of Ihr inilral valve, bill if Ihc aorlic disease is the resull (d' sypliilis. hard work, or aiiemysm 



212 ENLARGEMENT OF THE HEART 

of the first part of the aorta, tlien it may be assumed that the mitral regurgitation is tlic 
result of secondary dilatation of the left ventricle, and not of primary mitral disease. 

Secondary to Increased Systemic Blood-pressure due to Chronic BrighVs Disease. — 
Associated with the increased blood-pressine of chronic Bright's disease, the left ventricle 
hypertrophies first, and after a time, when compensation fails, dilates ; mitral regurgitation 
follows, and may be succeeded by all the signs of backward pressure, such as oedema of the 
feet and legs, ascites, enlargement of the liver, hydrothorax, ha^moj^tysis from congestion 
or infarction of the lungs, and so forth. A patient presenting such a group of. symptoms 
may at a first glance be considered to be a case of primary disease of the heart, but a careful 
investigation will often enable one to determine that the jirimary changes liave occurred 
in the kidneys. The radial artery may be thickened and tortuous, the ten.sion of the pulse 
higher than in mitral regurgitation from ])rimary heart disease ; there may be albimiinuric 
retinitis and retinal lucmorrhages : the urine is variable, for whereas it may formerly have 
been abundant, of low sjiecifie gravity {1((08 to 1012). with only a trace of albumin, heart 
failure may lead to its being diminished in amount, of specific gravity 1020 or more, and 
albumin may be abundant ; microscopical examination, however, will generally re\-eal 
renal tube-casts. 

Secondary to Increased Systemic Blood-pressure due to Primary Arteriosclerosis. — In this 
disease there may be signs of enlargement of the heart, mitral regurgitation, backward 
|>ressure, and a thickening of the arteries, but in contrast to chronic Bright's disease the 
urine will be of higher specific gxavity, and there will be no albuminm'ic retinitis. It often 
becomes merely a matter of opinion, however, whether a given patient is suffering from 
arteriosclerosis or from granular kidney ; post-mortem examination may reveal both, or 
arteriosclerosis may predominate when granular kidney had been diagnosed, and vice versa. 

Diseases of the Myocardium and Pericardium. 

Myociirdilis — InHannnation of the myocardium is associated most frequently with 
either pericarditis or endocarditis, but occasionally it may occur in acute rheumatism as 
a primary condition. In one form of the disease there is an infiltration of leucocytes between 
tlie muscular fibres — interstitial myocarditis : in another form the actual muscle fibres 
are involved — parenchymatous myocarditis : and tliere is a third variety wliich occurs in 
])^•a■mia, especially from bone disease, characterized by the formation of abscesses in the 
myocardium. The weakened condition of the heart muscle leads to dilatation of the 
\entricles, and thus to enlargement of the heart. When accompanied by pericarditis or 
endocarditis, the signs of myocarditis are overshadowed by the symptoms associated with 
these other conditions. The diagnosis of myocarditis is therefore a dilHcult matter. If in 
a case of acute rheumatism there is no evidence of either pericarditis or endocarditis, but 
there are signs of cardiac failure, a feeble irregular pulse, a good deal of precordial pain and 
distress, dyspna?a and palpitation, a tendency to sudden collapse, and signs of dilatation 
of the left ventricle, with a feeble cardiac impulse and a weak first sound, myocarditis may 
be suspected. 

F(dty Heart. — The heart may be covered with fat (fatty sujK'rposition) ; fat may 
infiltrate between the muscular fibres (fatty infiltration) : the muscle fibres may be 
degenerated, losing their striation, and containing fat granules (fatty degeneration) ; or all 
these conditions may be associated. Fatty degeneration may occur in ])atches or be general. 
When general, the heart becomes enlarged from dilatation as the muscle becomes flabby, 
lias less contractile force, and is more yielding. It is a condition wliich may be associated 
with general obesity, severe auiemia, wasting diseases sucli as cancer, jjlithisis, phosphorus 
poisoning, and alcoholism^, It may be a secjuela of severe attacks of typhoid and other 
specific fevers. The symptoms and signs of the condition are due to the diminished 
contractile power of the ventricles which leads to dilatation. The pulse may be small, 
feeble, and slow — 30 to 40 beats i)er minute — or It may be frequent and irregular. The 
cardiac impulse is very feeble or imperceptible. There may be an increased area of cardiac 
dullness from dilatation, and the first sound may be very faint. The patient is usually 
feeble and anaemic, and suffers from faintness or severe syncopal attacks which come on 
suddenly and are characterized by coma, convulsive twitching, and stertorous breathing. 
CEdema of the legs and venous congestion of the lips and face, which are common in valvular 
disease, are usually absent. There is dyspnoea on exertion, a feeling of coldness and depres- 
sion, and a general impairment of the nutrition of the nuiseles, which are soft, flabby, and 



EXLARGE31EXT OF THE HEART 213 

(iiininished in power. In some cases attacks of cardiac ' astliiua ' in the early morning 
arc conijjlained of, and in the later stages of the disease there may be Cheyne-Stokes 
breathing. The chief diagnostic signs are the feeble cardiac impulse, the feeble pulse, and 
the weak first sound, associated with dyspnoea and attacks of syncope, and the absence of 
evidence of other causes for the heart symptoms. 

Fibroid Ilciiii. — Fil)roid degeneration of the myocardium is usually associated with 
some obstructive lesion of the coronary arteries caused by syphilis. It may be general, 
or rarely localized to the apex of the left ventricle ; in the latter case there may be 
thinning and weakening followed by aneurysm of the heart, and then by rupture. It is 
one of the causes f)f sudden death. The most important symptoms are : dyspnoea on 
sligiit exertit)n, palpitation, and precordial pain. The physical signs are those of dila- 
tation of the left ventricle. The pulse is slow, and in late stages feeble and irregular. 
Tluic inay be severe attacks of angina j)ectoris. The diagnosis is more or less a 
matter of guesswork. Such signs and symptoms in a patient who has had syphilis, 
but neither acute rheumatism nor chorea, and who has neither aortic disease nor signs 
of granular kidney or arteriosclerosis, might be considered indications of this form of 
cardiac degeneration. 

Periciirditis. — In j)ericarditis the cardiac impulse is usually displaced, and the area 
of cardiac duUness increased. These ])liysical signs may be due to enlargement of the 
heart, or to cllusion of serous fluid into the pericardial sac, and it is very difficult to differen- 
tiate between these two conditions. Enlargement of the heart due to dilatation is generally 
the result of the myocardium being affected as well as the pericardium, and the cardiac 
impulse is diffused and displaced outwards. If there is an effusion of serous fluid into the 
|)eri(iirdial sac, it is said that the impulse is displaced iipzctirrls as well as outwards, so that 
it iiia\- be found on a level with, or above and ixtciiial lo. I lie left nip|)le, but this is a very 
umchable sign. The dullness is increased laterally and upwards, and when carefully 
mapped out it is said to have a triangular shape, with the base on the diaphragm and a 
somewhat roimded apex pointing towards the left clavicle, and reaching to the second 
left intercostal spiiee or higher. Percussion. Iu)wever, is (|uile unable to distinguish between 
a pericardial effusion and a much enlarged heart without i IfusioM. The intercostal spaces 
are filled out, and may be almost obliterated, so that the ribs feel nmeh less prominent on 
this piirl of the chest. On auscultation, in addition to a systolic murmur at the impulse 
due lo mitral ineompetenee from the accompanying dilatation of the left ventricle, a triple 
"cantering' sound, and perhaps a definite rub, may be heard in some ))art of the piecordial 
region, especially near the stermmi, independently of respiration, and generally increased 
in inlensily by lirni pressure of the stethoscope. The rul) is audible whether en'usion is 
priMMl or not . 

.Icllififiil I'liiidriliiini. -Adiiesions belwceri Ihc vIsccimI and paiii-tal laNcrs of I he 
|)(iii-anliuMi arc found frecpiently j)ost niorlcni win ii lliiy IkhI ucNcr l)een suspected <luring 
Mfc. Soniclliucs, lu)wever, they arc assoeialeil with chroMic lucdiMstiiiil is. or wlial should 
mure correct ly be termed mediastinal fibrosis, the outer surface of the pericaidial sat 
beeoiuing adherent to the thoracic wall and to adjacent structures. This condilioii usually 
leads to cojisiderable hypertrophy and dilatation of the heart. There may be marked 
bulging of the precordial area to the left of the sternum. The cardiac impulse may be seen 
not only in the sixth space outside tlu' left nipple line, but also in the fifth, fourth, and third 
left spaces, and the pulsation may extend in these s))aees from the left border of the sternum 
to the left nipple line, or even outside that line. The impulse has a curious wavy character, 
and il may be noticed that eoineident with the im|)ulse in the sixth space there may be 
a systolic retraction of tin- sp:iees abo\c. or of llie lower libs below and outside the cardiac 
urea, best seen when the patient lies over lo the other side with his left arm raised above his 
head. If the liciul is aillicicnl lo the diaphragm, there may be a systolic relraetion of tlu- 
eleventh aiul twcMlli rihs un Ihc kit side behind. Some eases of adhereul pericardium of 
this type exhibit dilatation of the superficial veins in the precordial area. Diastolic collapse 
of th<- eer\ieal veins is said to occur also. On rolling I lie pal ien I from side to side i I is found 
in many cases tlial the cardiac impulse remains nearly in the same position, not altering 
so niui'li as it does in health under similar cireumstances. The hand placed over Ihc heart 
ni:i\ \vr\ II diastolic shock or rebound, which is regarded by some as ;i characteristic sign 
III llie I'liiKJII Ion. On aiisciillal i'lii llicrc iii:i\ lie a systolic innrinnr al llic a|icN. iniliealive 



214 enlarge:ment of the heart 

of mitral regurgitation, and frequently there is also a ])re-systolic nunnuu- due to a relative 
stenosis of the mitral orifice. 

There is also a therapeutic sign which may help in doubtful cases. Mitral regurgitation 
in yoimg people, if due simply to fibrosis of the valve after endocarditis, will usually improve 
under treatment by rest in bed and the administration of appropriate doses of digitalis. 
Where the mitral regurgitation, however, is associated with adherent pericardium, similar 
treatment has little effect, and very slight, if any, improvement follows. If, in a young 
person who is presumably rheumatic, the size of the heart and the symptoms are not easily 
accountable for by the extent of valvular disease suggested by the bruits, the patient 
probably has adherent pericardium with mediastinal hbrosis. The diagnosis, therefore, is 
guessed at rather than made. 

Acute Dilatation of the Heart. 

From Ovcr-c.rerlioii. — Acute dilatation may result from over-exertion. For example, 
if a man who lias been run down from excessive mental work, and in consequence is in poor 
condition or l)ad training, takes a holiday, and attempts the ascent of a mountain or engages 
in some violent form of exercise, his heart is very liable to give way under the strain. The 
chief indication of such an occurrence will be a feeling of pain, distress, and discomfort in 
the region of the heart, dyspnoja, and palpitation. The pulse will be rapid, weak, and 
irregular. The cardiac impulse will be displaced outwards, diffuse, weak and undulating 
in character, and althougli a maximum ])oint of the impulse may be visible, it cannot be 
located clearly by palpation. There will be epigastric pulsation, the cardiac dullness will 
be increased outwards, and tlie first sound will be feeble, reduplicated, or rei)laced by a soft 
blowing systolic murmin-. 

From Acute Specific Fevers. — Similar signs and symptoms, especially weakness of the 
first sound, occurring in the covn'se of diphtheria, typhoid fever, typlius, scarlet fever, 
erysipelas, and other fevers, woidd point to dilatation of the heart in consequence of the 
tox;enn'a ])roducing loss of tone in the cardiac muscle from parenchymatous degeneration. 

3. Arteriosclerosis and Granular Kidney (see p. 14). 

4. Alcoholism. 

Patients who have been addicted to alcoholism are hable to enlargement of the heart. 
It is a cause of which the importance is frequently overlooked. The usual signs of hyper- 
trophy and dilatation may be present, with mitral and tricuspid incom])etence and signs of 
backward pressure. The enlargement may be considerable. At a post-mortem examination 
it is by no means unusual to find the heart weighing as much as from 20 to SO ounces. The 
valves are liealthy, the aorta normal, and evidence of arteriosclerosis and granular kidney 
is absent. Alcoholism may be suspected as the cause of enlargement of the heart where 
there is no evidence of primary valvular disease, adherent pe^^icardium, arteriosclerosis, 
or chronic Bright's disease. Other signs of alcoholism may also be present (p. 720). 

'). Long-continued Over-exertion 

produces hypertroiihy of the ventricles ; for a considerable ]Deriod there may be no symptoms, 
but after a time, when compensation fails owing to tfie hypertrophy being insufficient to 
continue the excessive work, dilatation is produced, and mitral incompetence and signs 
of backward pressure ensue. The subjects of this form of enlargement of the heart are 
usually eitlier middle-aged men who are robust and healthy in appearance, but have had 
to follow for many years a laborious occupation entailing severe manual labour, or else 
young men of good physique who have indulged in excessive athletic exercises, sucli as 
rowing, football, boxing, and running, often with insufficient preliminary training. At 
first, palpitation, dyspnoea, and irregular cardiac action arc noticed. Later the ventricles 
dilate and the mitral valves become iiieonipetent, and all the signs of backwai'd pressure 
may follow. Enlargement of the heart from this cause is much more liable to occur where 
the patient is accustomed to take a considerable amount of alcohol. As a cause of enhirge- 
ment of tlie heart it should not be diagnosed until primary valvular disease, granular kidney, 
and arteriosclerosis can be excluded. 



ENLARGEMENT OF THE HEART 



6. ExopiiTiiAi-Mic Goitre. 



In this disease, moderate enlargement of the heart, as shown by the displacement 
outwards of tlie cardiac impulse and the increased area of cardiac dullness, is common, and 
is probably the result of the long-continued increased rapidity of cardiac action. It is rarely, 
however, the most prominent sign of the disease. It is distinguished from other forms of 
enlargement by the presence of tachycardia — the pulse-rate in a well-marked ease varying 
between 120 and 160, or being even higher than this — the marked pulsation of the carotids 
and other superficial arteries, the exophthalmos, the enlargement and pulsation of the 
thyroid gland, the fine tremor of the extremities, the loss of weight, the excitability, and 
the pigmentation of the skin of the eyelids. There is very often a loud blowing systolic bruit 
in the pulmonary area, less often one at the impulse, but frequently one over the thyroid 
gland. Certain signs associated with the names of von Graefe, Stellwag, and Moebius, 
are not of the least value in making the diagnosis. 

7. CoNOExiTAi, Heart Disease. 

When there is a patent interventricular septum there may be considerable enlargement 
ul' the heart from hypertrophy and dilatation of both ventricles. It is frcfiuently associated 
with some narrowing of the ])ulmonary orifice. In addition to the symptoms common to 
most forms of congenital heart disease, viz., cyanosis, clubbing of the fingers and toes, 
dyspnoea, and polycythsemia, the cardiac impulse will be displaced downwards and outwards, 
there will be epigastric pulsation, perhaps a prolonged systolic thrill, best felt over the third 
left intercostal space close to the sternum, an increased area of cardiac dullness in all direc- 
tions, and a loud systolic murmur at the base of the heart, the ])oint of maxinuim intensitv 
being the tnird or fourth left intercostal space close to the left border of the sternum. It is 
often very dillicult to say whether the lesion is pulmonary stenosis or jiatent interventricular 
septum. A well-marked thrill is associated more constantly with the former than with the 
latter, but the point of maxinnmi intensity of the murmur produced by pulmonary stenosis 
is in the second left space, close to the left border of the sternum, whereas in i)atent inter- 
\cntricular septum the murmur is loudest lower down. 

ENLARGEMENT OF THE RIGHT VENTRICLE. 

Wlien the eiilargcincnt of the heart is i\w to hyperhnphy or dilatation of the right 
Nciilricle. Ihc cardiac impulse is displaceil outwards more than downwards, tliere is fre(|ucntly 
well-marked epigastric |)ulsation. and ttie (hillness is increased upwards and to tlie right 
rallicr than to the left. The causes of enlargement of the right \ eritriele are as follows : — 

1 . Diseases of the Left Side of tlie Heart : 

-Mitral stenosis 

All the eoTiilitioiis wliieli cause eiihn^eiiieiil of llie Icjl \eiiliiele (p. 200). 

2. Diseases of the Lung : — 

Kil>roj>l liiii^ 

(linjriie JM-orieliitis ;iii(l eiiipliyseinii. 

:s. Diseases of the Right Side of the Heart : — 

('on;{('iiil:il piilinoiiarv stenosis 

I'lilnii y ineoinpet'enee : (i) Due In ililal:ilion ol'llir pul larv artery; 

(ii) line to infective eiuloeanlilis of lije pnirnonary \:i\\r. 

1. Disi.Asi'.s oi- riii; Li;i-r Smr, ov iiii-; IIi^Aur. 

Mitral Stenosis. — This is a common and most important eanse of enlargenient of the 
riylit veiilricle. The obstruction to the How of blood from the lelt auricle into the left 
ventricle leads to hypeitrophy and dilatation of the left auricle, passive congestion of the 
lungs, red and brown indnrat ion of these organs. I liieki'iiing dilatation and allieroina. of the 
branches of the pulmonary arteries in the hmgs as a result of the iner<ased tension in these 
vessels. .Ml these changes increase the amount of work to he perlormed by the right side 
of the heart, and arc rcsixaisihle foi- the hyp<rt ropliy of the right xciitiicle, by which 
means compensation niav lie maintained for some time. When the right \-entriele dil.-itcs. 



216 enlarge:ment of the heart 

compensation fails. In the early stages the pulse shows little variation from the normal, 
and there may be no obvious symptoms pointing to the existence of mitral stenosis. In more 
advanced phases the pulse becomes rapid, small, and irregular. The cardiac impulse is 
displaced outwards, and pulsation occurs in the epigastrium and in the third, fourth, and 
fifth intercostal spaces close to the sternum. On placing the palm of the hand over the 
region of the cardiac impulse and the adjacent fourth and fifth intercostal spaces, a character- 
istic thrill may be felt. It usually has a curious rough grating quality. It is diastolic in 
rhythm, and may be felt to terminate suddenly in a sharp shock which is synchronous witii 
the apex beat. The dullness is increased upwards from the third left rib to the second, 
or even higher ; it extends well to the right of the sternum, but it does not reach far to the 
left, though in a few cases it extends to the lef